DISORDERS OF PERCEPTION

Sharath. M
M.Phil. CP.
1st Year (New)
 S ENS ATION

What is sensation?
• The process through which the sense pick up visual, auditory, and other sensory stimuli and transmit
them to the brain.
• Sensory information that has been registered in the brain but has not been interpreted, is called
sensation.

How sensation occurs?

• The receptors cells contained in sensory organs, such as eyes, ears, skin, nose and tongue, receives
all the raw sensory data.

• Next, by the process of Transduction, the sensory signal are converted to electrical signal and sent to
be processed in a specialized area in the brain.
 PERCEPTION

• Information >>> Detection >>> Sensation >>> Transduction >>> Perception

• What is Perception?
• Perception is the process through which people take raw sensation from the environment and

interpret them, using knowledge, experience and understanding of the world, so that the
sensation becomes meaningful experiences.
• In general, it can be defined as “ a process that involves sensing, receiving, selecting,

organizing, interpreting and giving meaning to the environment.”

• It Involves active processes that are influenced by attention, affect, cultural expectations, context,
prior experiences, memory and, most importantly, prior concepts.
 INFORMATION PROCESSING

• The way we integrate and analyze sensory input depends on various factors.
• Two ways have been conceptually outlined:
o Bottom- Up: Integrating features of the stimuli
• Low cognition, organize information using senses- 3 horizontal, 2 vertical lines

o Top- down: Interpreting information after feature detection

• High cognition, schema driven interpretation based on prior knowledge or contextual factors.

• ABC and 12,13,14

• The way we integrate and analyze sensory input depends on various factors.
 DISORDERS

• Sensory Distortions & Sensory Deceptions

• Distortions: Real perceptual object which is perceived in a distorted way

• Intensity

• Quality

• Spatial form

• False perceptions or Deceptions:

 INTENSITY

• The intensity at which the sensation is perceived is heightened (hyperesthesia) or decreased

(hypoesthesia).
• Example:
• Ordinary conversation may sound intolerably noisy, and even whispering at a distance may be found
uncomfortable.
• Anxiety and depressive disorders, hangover from alcohol and migraine, associated with increased sensitivity to
noise (hyperacusis) such that even everyday noises like washing utensil's are magnified to the point of
discomfort.
• Visual and gustatory sensations may also be lowered in depression, for example, everything may look black or
all foods taste the same.
 QUALITY

• These are mainly visual distortions brought about by toxic substances which color all perceptions.

Altered color perception in one or both eyes.

• Xanthopsia: coloring of yellow (santonin drug)
• Chloropsia: coloring of green
• Erythropsia: coloring of red
• Most common, metallic taste associated with the use of lithium, although this is not a hallucination,
but a true change in gustation.
• Erythropsia has been reported following pre-retinal and vitreous hemorrhage and blindness after
electric shock.
• These are not hallucinations but qualitative changes of perception brought about by the drug.
 SPATIAL FORM

• Change in the perceived shape of an object.

• Micropsia- Seeing objects smaller than they really are or farther away than they really are.
• Macropsia or Megalopsia- This refers to the visual disorder in which the patient sees objects as larger
than they really are.
• Can be caused by various organic conditions like retinal disease, accommodation and convergence

disorders, temporal and parietal lobe lesions.

 SPATIAL FORM

Changes in Spatial form (dysmegalopsia)

 S ENS ORY DEC EPTION

• Illusions: Are misinterpretations of stimuli arising from an external object. Stimuli from perceived

objects are combined with a mental image to produce a false perception.

• Not necessarily indicative of psychopathology.

• Can occur in any modality. Hearing your name, hair on skin, shadows as following.

• Important to probe and distinguish between hallucinatory experiences or illusory experience.

 ILLUSION

• Completion Illusion: These depend on inattention such as misreading words in newspapers or missing

misprints because we read the word as if it were complete.

 ILLUSION

• Affect Illusion: occurs at times of heightened emotion.

• While walking through a dangerous area late at night a person may see a tree blowing in the wind as an attacker
attacking at them).
• Emotion determines the identification of the perceived object, but focused attention clarifies the error.

• Pareidolia: vivid illusions occur without the patient making any effort, cannot therefore be explained as
the result of affect or mindset.
• Most commonly quoted is seeing pictures in fire or in clouds, without any conscious effort. Previously known to
be a symptom of psychosis.
 HALLUCINATION

• Perception without adequate external stimulus. They come from within, though perceived a coming from

outside.
• Slade (1976)- defines three criteria are essential for an operational definition:
• percept-like experience in the absence of an external stimulus
• percept-like experience that has the full force and impact of a real perception
• percept-like experience that is unwilled, occurs spontaneously and cannot be readily controlled by the percipient.
• They can be intrusive. Internal source. Incorrectly attributing to an external source.

• Different modalities, causes and types.

• Hallmark feature of psychosis. Not limited to schizophrenia.
 C AU S ES

• EMOTIONS: Very depressed patients with delusions of guilt may hear voices reproaching them. These

are not the continuous voices of paranoid schizophrenia or organic hallucinosis but tend to be disjointed
or fragmentary, uttering single words or short phrases such as “kill yourself”.
• If continuous persistent hallucinatory voices in severe depression, then probe for schizophrenia.
• SUGGESTION: Several experiments have shown that normal subjects can be persuaded to hallucinate.
Gazing at one's own face in the mirror for a few minutes, at a low illumination level, produces the
apparition of strange faces.
• PERIPHERAL ORGANS: Eyes, ears, nose, tongue.
• Charles Bonnet syndrome refers to visual hallucinations. Some people who lose vision from age-related macular
degeneration (AMD) or other eye disease hallucinate or see things that aren't really there.
 C AU S ES

• SENSORY DEPRIVATION: If all incoming stimuli are reduced to a minimum in a normal subject, they

will begin to hallucinate after a few hours.

• Black Patch Psychosis or Cataract Delirium, is a postoperative condition of an acute confusional state dominated
by complex visual hallucinations in individuals wearing a bilateral eye patch following cataract surgery. Visual
parts no longer getting any input, they become hyperactive and excitable and fire spontaneously.
• DISORDERS OF CNS: Trauma, Infections, Degeneration, Structural Defects, CNS tumors, Stroke,
Lesions.
 AU DITORY

• Hearing voices. These are audible thoughts, voices heard arguing with each other and voices commenting

on the patient’s behavior (Schneider 1st Rank Symptoms).

• In acute organic states, the auditory hallucinations are usually unstructured sounds – elementary
hallucinations, for example, the patient hears whirring noises or rattles, whistling, machinery or music.
Often the noise is experienced as unpleasant and frightening. Also Prodromal disturbances sometimes.
• Hearing voices also occurs occasionally in other conditions, such as chronic alcoholic hallucinosis or

affective psychoses. Delirium, Dementia and severe depression (less well formed).
• Voices giving instructions- imperative hallucination. May or may not act on them.
 AU DITORY

• The effect of the voices on the patient’ s behavior is variable. A number of patients (becoming fewer in

number with advances in treatment) have continuous hallucinations that do not trouble them.
• Abusive, Neutral, Helpful, Incomprehensible nonsense, Neologism.
• Patients explain the origin of the voices in different ways. They may insist that the voices are the result of

witchcraft, telepathy, radio, television and so on.

• Sub-vocal speech. Patients hearing voices have slight movements of the lips tongue and laryngeal

muscles and that there is an increase in the action potentials in the laryngeal muscles.
 VIS ION

• Visual. These may be elementary in the form of flashes of light, partly organized in the form of patterns,

or completely organized in the form of visions of people, objects or animals.

• Visual hallucinations characteristically occur in organic states rather than in the functional psychoses.
• Among referrals to a psychogeriatric service, visual perceptual disturbance occurred in 30% of patients;

there was a strong correlation between the presence of visual hallucination and eye pathology.
• With psychomimetic (mimicking psychosis) drugs, there are alterations in spatial perception, in the

perception of movement and in the appreciation of color, and visual illusions and hallucinations may
occur.
• Charles Bonnet’s syndrome.
 OLFACTORY

• Hallucination of Odor. Olfactory sensation or memory is often associated with powerful emotional

resonances; it is not surprising, therefore, that hallucinations are also invested with a strong affective
component.
• Odor information is relayed directly to the limbic system, a brain region typically associated with

memory and emotional processes.

• Can occur in schizophrenia and organic states and, uncommonly, in depressive psychosis.

• Sometimes the smell may be pleasant, for example, when some religious people can smell roses around
certain saints, this is known as the Padre Pio phenomenon.
 GUSTATION& TACTILE

• Hallucination of Taste. Occur in schizophrenia and acute organic states.

• Depressed patients often describe a loss of taste or state that all food tastes the same.

• OH and GH frequently co-occur, and because of their complexity have not received a lot of attention in
imaging studies.

• Hallucination of Touch. In depression and in schizophrenia, the flavor of food may disappear altogether

or become unpleasant.
• In schizophrenia, they sometimes occur with delusions of being poisoned.
 TAC TIL E

• Types of tactile
• Superficial: affects the skin.
• Thermic- feeling cold wind blowing on them
• Haptic- feeling like hands brushing against skin
• Hygric- like water (fluids) flowing from the head to stomach
• Paresthetic- feeling pain like sharp object
• Kinesthetic: affect the muscles and joints, and the patient feels that their limbs are being twisted, pulled or moved.
• Can be seen in schizophrenia organic states such as alcohol intoxication and benzodiazepine withdrawal.
• Visceral: A deep and pain sensation, patient complaints of twisting and tearing pain.
• Bizarre complaints of flesh ripping from body and organs being taken out. seen in chronic schizophrenia.
• Delusional Zoopathy- occurs in organic states, a delusional belief that animals are crawling over body with a
hallucinatory component to it.
 SENSE OF PRESENCE

• Most normal people have from time to time the sense that someone is present when they are alone, on a

dark street or climbing a dimly lit staircase. Often the feeling is that there is somebody behind them.
• Usually this is dismissed as imagination, but nevertheless they look behind them to be certain.
• Lack of sleep and hunger.

• Misperceiving source and identity of sensorimotor signals from own body.

 HAL L U C INATORY S YNDROMES

• Hallucinatory syndromes, also termed hallucinosis, refer to those disorders in which there are persistent
hallucinations in any sensory modality in the absence of other psychotic features.
• Alcoholic hallucinosis: These hallucinations are usually auditory and occur during periods of relative abstinence.
They may be threatening or reproachful, although some patients report benign voices.
• Organic hallucinosis: These are present in 20– 30 per cent of patients with dementia, especially of the Alzheimer
type, and are most commonly auditory or visual. There is also disorientation and memory is impaired.
• MRI Impression: Dementia with Psychotic features.
• White Matter Hyperintensities: Chronic Ischemic Changes due to small vessel disease.
• Neuroparenchymal Atrophic Changes.
• Ex.1: Tries to listen and answer in English upon hearing a meaningless speech of a Intellectually Disabled
women next to her.
• Ex. 2: Feels that someone is talking about ‘Us’ or calling her name on hearing a loud random noise. Hears
the sound of a car and says “The king of this building is back again”.
 S PEC IAL KINDS

• Functional Hallucination: Hallucination induced by a real sensory experience.

• Voice of God talking to her as the clock ticked. Dog barks I feel like washing clothes or throwing food.
If dog braking lead to her seeing figures or hearing voices then functional.
• Patients who discover that noises induce hallucinatory voices put plugs in their ears to reduce the
intensity of the stimulus and hence the hallucinations.
• Reflex Hallucination: Stimulus in one sense and hallucinatory experience in the other.
Morbid variety of Synesthesia.
• Extracampine Hallucination: experienced outside the limits of the sensory field, outside the
visual field or beyond the range of audibility. experienced as a perception by the patient and
not just as a belief or an idea.
 S PEC IAL KINDS

• Autoscopy or Phantom Mirror-Image: Experience of seeing oneself and knowing that it is oneself.

see an image of themselves in external space viewed from within their own physical body
• In autoscopic hallucination, the percept is often but not always a mirror image of the patient.
• Internal Autoscopy- Sees own internal organs.
• Negative Autoscopy- Looks in the mirror and sees no image.
• Occasionally seen in schizophrenia, but are more common in acute delirious states. Normal, emotionally
exhausted patient.
• Hypnogogic: Abnormal perception cause of increasing drowsiness while falling asleep. The structure of
thought, feelings, perceptions, fantasies and, ultimately, self-awareness becomes blurred.
 S PEC IAL KINDS

• Hypnopompic: Abnormal perception on waking, persists even when eye open.

• Not indicative of psychopathology even though they are true hallucinatory experience.
• Both are described in Narcolepsy and other sleep disorders. Hypnopompic a better indicator of Narcolepsy.
• Organic Hallucination: Neurological and psychopathology. The phantom limb is the most common

organic somatic hallucination of psychiatric origin.

• Pseudo hallucination: Perceptual experience that is figurative and occurs in inner subjective space, not in
external objective space.
• Described by the patient as a voice but is actually recognized as his own thoughts. Not pathognomonic of any
particular mental illness.
• Refers to hallucinations with insight (Hare, 1973), and on the other hand to vivid internal images.
 OTHER WAYS

• Signal Detection Theory: Psychophysics. Quantitatively investigates the relationship between physical

stimuli and the sensations and perceptions they produce.

• Most common application is Stroop Effect. Executive Functioning.
• Omission and commissions.
• Present and perception: Normal
• Absent and perception: Hallucination.
• Apophenia: the perception of meaningful patterns where none exists.

apophenia can be seen as synonymous with a disposition toward

Type I errors (false positives) in both perception (as in hallucinations)
and belief (as in delusions).
 OTHER WAYS

• Sensory Gating: Protective mechanism.

• Neurophysiological processes of filtering out redundant or irrelevant stimuli from all possible environmental
stimuli reaching the brain, allowing for coherent thought. Deficits in sensorimotor gating may result in stimulus
overload and the misinterpretation of sensory information.
• Schizophrenia: P50 ERP wave, occurring 50ms after stimulus presentation is used to measure sensory gating.
Besides schizophrenia, abnormal P50 suppression has been found in patients with traumatic brain injury,
recreational drug use, and post-traumatic stress disorder.
• In a paired click test, one auditory click sound followed by a second click approximately 500ms after the

first one. The second sound is considered redundant, normal sensory gating will produce a reduced
response to the second click.
• Abnormal P50 suppression in paired click tests can be found through either a failure to suppress the

second stimulus, or as a failure to produce a heightened response to the first stimulus.

 REFERENCES

o Oyebode, F. (2022). Sims’ Symptoms in the Mind: Textbook of Descriptive Psychopathology.

Elsevier Gezondheidszorg.

o MedLink Neurology. https://www.medlink.com/media/rtrp1

o Casey, P., & Kelly, B. (2007). Fish’s Clinical Psychopathology: Signs and Symptoms in Psychiatry
(4th ed.). RCPsych Publications.

o Disorders of the CNS System.

https://med.libretexts.org/Bookshelves/Nursing/Nursing_Pharmacology

o Hallucinations related to eye disease have brain basis.

https://qbi.uq.edu.au/article/2018/10/hallucinations-related-eye-disease-have-brain-basis
Thank you