Sunday, January 27, 2013

Types of hallucinations

Tactile hallucinations

In psychiatry, psychopathology of touch has been subordinated to other symptoms and has little interest diagnosis3, 30. This reflects both its uniqueness as the conceptual difficulty implicit in its definition. From the Greeks touch has been a "reluctant fifth sense." Aristotle considered it a "primitive perceptual system," distinguishing it from the senses 'distal'. This approach continued until the seventeenth century when the British empiricists epistemology made another touch. Thus, Locke opposed the Cartesian philosophy according to which the "extension" is the essence of material substance, maintaining that in addition to the "extended substance" all bodies possess the fundamental quality of the "solidity". Body information that supports the concept of "strength" comes from the "feelings of resistance" and "motor sensations." This idea was picked Armstrong136 to note that the term "feel" has at least two forms of sensory perception: the "perception by touch" and "perception of our own body condition." Weber introduced this distinction in psychology with the concepts of "touch" and "common sensibility" (see below) 1.

In classical authors such as Darwin, Esquirol and Sigmond, are descriptions of "imaginary itch." Griesinger made the fundamental observation that in the psychopathology of touch is not possible to distinguish hallucinations from illusions, rather all illusions phenomena should be considered as the specific alteration is a false interpretation of certain sensaciones1, 3.

In this type of tactile hallucinations, also called haptics, patients are touched, pinched, or describe sensations of heat, cold, itching, cramping, etc.. These phenomena can exist alone or be part of a delusional system. The classic description of tactile hallucinations cocaínica appears in intoxication (Magnan and Saury, Clerambault) and belladonna (Moreau de Tours) and these patients have a feeling that many insects move under the skin. To call these phenomena were minted and imaginary terms formicación1 psora, 3.


Experience concerning the interior of the body, ie deep sensitivity. The French concept of cenestopatía reflects the conceptual distinction between senses of previous German skin (Tastsinn) and common sense (Gemeingefuhl) 1, 3. The latter refers to all bodily sensations that persist once separated all those associated with the skin (ie, touch, temperature, pressure, position). So, include pain and sensations "None" as well, pleasure, fatigue, hunger, nausea, chills, muscular sense, etc.. This group also called coenestesia137 sensations and some have considered the basis of a "meaning of life" 138. To explain this bodily sense of "unity" Two theories have been proposed: the association was held that the sum cenesthesia of proprioceptive and interoceptive sensations, for its part, the faculty psychology postulated the existence of a hypothetical function or brain center converging the sensations. This mechanism also sat the basis for developing the concept of "body schema". However, soon after its emergence, the functional territory cenesthesia wore on separation, and studied independently, feelings such as hunger, thirst or sexual pleasure. In the end, only feelings were shared by several organs as deep pressure, pain, or sensations such as tingling unanalyzable, shivering or chills.

In this historical moment introduces the term Dupré cenestopatía in French psychiatry as "local alteration common sensitivity in the area of ​​general feeling that corresponds to hallucinosis in the area of ​​sensorium» 139. For Dupré, cenestopatía concept includes a wide range of somatic complaints resulting from an alteration combined imagination and emoción140. He recognized two major groups cenestopatías - "painful" and "paraestésicas" and each is divided into cephalic, thoracic and abdominal. Patients in the first group felt their bodies "stretched, torn, twisted" and the second experienced itching, hyperesthesia, paresthesia, etc.. The syndrome was never accepted by Anglo psychiatry, which reclassified these symptoms as hypochondriasis, neurasthenia or dismorfofobia141. In France itself, some cenestopatías like cenestopatía topalgia or cephalic, were later classified as "neurovegetative dystonia" or psychosomatic syndromes. Other authors studied the same phenomena as "disorders of body schema," "subjective conditions of sensibility" or "psychoneurosis." Finally, other entities such as chronic tactile hallucinosis or delusional parasitosis rose to almost independent categories. The delusional parasitosis is a complex clinical phenomenon in which patients, maintaining a normal state of consciousness, complain of being infested with insects or parasites. Sometimes accompanied by visual hallucinations that complicate the clinical picture. Since the first descriptions in the nineteenth century, known by terms like "acarofobia ',' parasitofobia" is still controversy as to whether the primary disorder is a delusion or a alucinación142.

Olfactory hallucinations

The olfactory hallucinations have been considered rare and of little clinical interest and, consequently, the treaties of psychopathology and psychiatry have addressed only ellas143. For example, in his Traité des Hey hallucinations devotes barely 16 pages of totales38 1543. This may reflect their lack of clinical and statistical significance but also the confusion about its conceptual status.

The descriptions of imaginary smells found in scriptures and manuscripts Egyptian physicians. Aretaeus of Cappadocia mentioned as signs of auras epilépticas144. Robert Burton's Anatomy of Melancholy, 1621 included in the "signs of melancholy in the body" 145. During the nineteenth century were described by Baillager146, in a hypnagogic hallucinatory state as "unique odor" associated with auditory hallucinations, visual, gustatory and kinesthetic. Esquirol granted the same importance and frequency as other alterations of perception and cites several cases of persecution complex olfactory hallucinations predominantly desagradables15. To register, however, are rare, rarer psychosensorial all manifestations, "are also less clear and less perfect (...) and are observed mainly in psychosis systematized and hypochondriacal psychosis' 147. Other authors, such as Baillarger145, Marcé148, Brierre of Boismont21 or Griesinger149, indicate that are almost constant in the beginning of psychoses, in the state predelirante, before the subject appear invaded by psychosis. Baillarger himself made the interesting observation that olfactory hallucinations, like the feel and taste, are difficult to distinguish from the olfactory illusions. Subsequently other authors, as Bullen150 and Griesinger148, held the same opinion and said that this difficulty is also true, to a greater extent, tactile and gustatory hallucinations. The debate continued in the twentieth century. For example, Mayer Gross argued that it was essential to maintain the existence of the olfactory hallucinations and delusions genuinas151. By contrast, Bleuler152, Conrad153 and Bumke154 argued that in the case of olfactory and gustatory hallucinations could never rule out the existence of a genuine perception because these senses are always under the influence of a sensory stimulus.

Classification of olfactory hallucinations

In 1892, Savage155 established the main characteristics and types of olfactory hallucinations, which can occur in both disease states and in states of psychic normality. The olfactory hallucinations are less common than other senses and simple and can be isolated or associated with other hallucinations, most often to the gustatory and tactile. They can be primary, and other symptoms arise from them, or secondary, usually developed from a delusion, and constant or sporadic. Regarding content, it can be pleasant or unpleasant more frequently and its origin may be due to central nervous system pathology or sensory organs.

Ey38 olfactory hallucination classified according to their content: pleasant (perfumes, odors or scents of flowers or voluptuous delicious sensations captured in an exquisite atmosphere) or unpleasant nauseating (gas odors, sulfur, chemicals, malodorous), character neutral (unusual or persistent odor of vinegar, vapors, metro station or onion soup), and indefinable character (smells "never senses" mysterious, ineffable, with a load of emotional distress or pleasure). Moreover, according to the impact they have on the patient classifies: dangerous or aggressive in nature, erotic, repulsive (organic putrefaction: fecal odor, body, gangrene) and mystic. Depending on the location may be: external and self-olfactory hallucination, wherein the odor source is the subject itself. Depending on their nature, e and classified as:

1. Olfactory Eidolias:
 they have a structure-alucinósica eidolo, ie partial olfactory phenomena, without elaboration delusional seen in neurological processes. In turn may be: phantéidolies found in Jackson uncinate crises due to injury temporo-sphenoidal (dreamy state), vegetative symptoms are accompanied by alterations and sensory-motor or sensory, are of intensity, can be very violent and duration is brief, and proteidolias, elementary hallucinations, unusual to be confused with the dreamy status.

2. Olfactory hallucinations delusions.

In general, during the nineteenth and twentieth olfactory hallucinations were described in four clinical conditions: psychosis, organic and toxic tables, neurotic states and delirium olfactory (délire olfactif base) and olfactory reference syndrome.

Olfactory hallucinations and toxic organic syndromes

The olfactory hallucinations in organic paintings have been described mainly in epilepsy, brain tumors and injuries craneoencefálicos156. Hughlings Jackson157, 158, 159 said their presence in the aura of uncinate seizures secondary to pathology temporo-sphenoidal lobe, accompanied most often symptomatic of an entourage that included vegetative phenomena, sensory-motor and sensory as well as a twilight state, dream ("intellectual aura" or dreamy state) characterized by the presence of feelings of unreality, estrangement and depersonalization with vague and imprecise memories ("reminiscences") and phenomena of déjà vu and déjà vécu. In some cases the olfactory hallucination are accompanied by other hallucinations, taste generally 156, 160. These phenomena olfactory aura in temporal epilepsy had Herpin161 described above, 162 in France and then, there have been numerous references to its presence in temporal163 lobe pathology, 164, 165, 166, 167 and in cerebral168 electrical stimulation.

The olfactory hallucinations appearing in epilepsy-primary or secondary to temporal lobe pathology-basic phenomena are often isolated and without significance precisa164. They are usually brief, lasting only a few seconds, although cases have been reported in which hallucinations have persisted for hours and has been called "bad hallucinatory state" 164.

The olfactory hallucinations have also been described in the aura of migraine, the alcoholismo169, 170, 171, 172, mescalina173 intoxication, LSD and other alucinógenos174 and efedrina175.

In some degenerative brain diseases, such as disease Alzheimer176, 177 Parkinson's disease and Huntington's chorea, alterations have been described in olfactory perception regardless of the presence of olfactory hallucinations.

In the alcoholic Korsakoff syndrome exists also an impaired olfactory detection and identification is absent in the non-alcoholic Korsakoff and is not explained solely by loss of short term memory or deterioration intelectual178. Finally, alterations have been described in the olfactory memory Huntington without any visual or auditivos179 deficits in Down180 syndrome and orbitofrontal181 lobe lesions.

Olfactory hallucinations in psychiatry

The olfactory hallucinations have been described in various psychiatric disorders. Some authors have tried to differentiate the characteristics of hallucinations of psychic origin of organic cause. For example, consider Paillas et al164 the former have a disagreeable emotional tone phenomena accompanied estrangement sensations kinesthetic presence and modifications, all together with a delusional elaboration. Described mainly by French psychiatry in chronic hallucinatory psychosis, delusions of influence, schizophrenia, delusional and melancolía38 bouffées, 156. In Anglo-Saxon psychiatry psychosis are all encompassed within the broad concept of schizophrenia except the so-called olfactory reference syndrome to be treated separately. However, we must bear in mind that in the work used different diagnostic criteria for different historical moments.

Chronic hallucinatory psychosis

For some authors olfactory hallucinations are common in this psychosis. Alliez and Noseda182 in a sample of 95 patients with olfactory hallucinations, 55 chronic hallucinatory psychoses would, have, in general, a nasty character and are associated with delirium, more or less rich and other hallucinations, mainly auditory, kinesthetic and especially , buds. Excepcional183 albeit, it is possible that in some cases the olfactory hallucinations acquire a new presentation: less frequent, have a nice content and delusional conviction disappears with a review, at least partially, of the above ideas and thus, with aware of the unreality of the phenomenon, ie to move from hallucinations hallucinosis, in the French sense of term2. To Paillas et al164, olfactory hallucinations in chronic hallucinatory psychoses are less autonomous character by associating constantly with feelings of estrangement or ideas of influence, along with other generally kinesthetic hallucinations. Furthermore, olfactory phenomena consist of a combination of illusions and hallucinations and delusions are integrated to form a delusional system.


The olfactory hallucinations may occur mainly at the onset of the different types of schizophrenia. The content is often unpleasant, internal or external location (such as odors from the body), and are associated with other hallucinations, verbal and kinesthetic, and despersonalización38 phenomena, 152, 184, 185. Thus, the subject acquires a new perception of the external world as both of his own body.

For most authors are rare olfactory hallucinations in schizophrenia. However, Bromberg and Schilder186 point in a review of 40 cases with schizophrenia olfactory hallucinations as the most common diagnosis followed by alcoholism, and Rubert et al. 187, according to authors like Sigmond188 (that considered frequent) point appearing in 83% of schizophrenics are more common (93%) in the chronic. Subsequent studies have lower figures, consistent with the view of classical authors-as-Griesinger and Bleuler believed that uncommon.

The ability to olfactory identification has also been studied in schizophrenia and in general it has been concluded that there is a decrease in misma189, 190, 191, although not clearly established the relationship between this dysfunction and clinical parameters, cognitive and biológicos192. Noted the existence of an association with the longer duration of the disease, increased negative symptoms, disorganized and more deficitario192 syndrome. Neuroimaging has proven the existence of anomalies in the medial temporal lobe (hippocampus and amygdala) 193. Kopala group holds that in schizophrenia there is an olfactory agnosia, ie an inability to recognize odors without a change in the olfactory acuity (anosmia) 194, 195, 196. Therefore suggest a cortical pathology and indicate that Korsakoff syndrome and orbitofrontal cortex lesions olfactory agnosia it happens.

Olfactory reference syndrome

The existence of primary olfactory hallucinations that lead to a secondary chronic delusional state moves into the foreground of the clinical picture has been suggested by several authors since the early twentieth century. For example, psychiatry francesa197, 198 délire based olfactive called syndrome consisting predominantly of primary olfactory hallucinations that lead to delirium, usually reference or persecution, based almost exclusively on them. Subsequently other authors as Porot and cols.199, MARTIMOR and cols.200, Alliez and Roger201 or Durand156 insist they consider this clinically rare but formal and clinical characteristics other than schizophrenia and other chronic psychoses. For the délire Alliez based olfactive is rare, in which olfactory hallucinations are usually unique, labile nature of body odor, and produce a hypochondriac and depressive reaction leading to isolation paciente202. The syndrome has a good prognosis and could be explained by a lesion in the temporal lobe. The olfactory hallucinations in schizophrenic psychosis have been described in kinesthetic hallucinations associated with delirium influencia203.

Similarly, in Germany, and Greger204 Popella describe two cases of what they believe a new diagnostic category, the "olfactory hallucinations monosymptomatic" (non-schizophrenic), which relate to previous contributions of other authors as Uberwertigkeits-wahnpsychose of Birnbaum205, hypochondriac paranoia (hypochondrische Paranoia) of Reichardt206 and monosymptomatic hallucinosis (monosymptomatische Geruchshalluzinose) Mayer-Gross151.

Videbech extensively described five cases of what he calls "olfactory paranoid syndrome chronic" 207, a special form of sensory development of personality characterized by paranoid ideas of body odor release, although not all cases are associated with olfactory hallucinations. The interpersonal relationship is marked by intense phobic reaction as the patient performs all acts, verbal and extraverbal, others as allusions to the stench. The course is usually chronic which inevitably leads to a marked social withdrawal and isolation. Also characteristic of the syndrome relief felt by patients and improved symptoms when they are alone or within their family circle. The previous personality is characterized by the existence of sensitive features, and obsessive perfectionists, with a marked feelings of inferiority.

With this background, Pryse-Phillips208, 209 identified syndromes clinicians appearing in olfactory hallucinations: schizophrenia, depression, epilepsy and focal called "olfactory reference syndrome." For Pryse-Phillips, olfactory hallucinations may be intrinsic, in which the patient perceives the smell emanating from his own body, and extrinsic, when located in outer space. The patient's reaction to the hallucinations may be "minimal", "reasonable" and "contrition". The latter refers to the sensitive reaction of guilt and shame felt by the patient when he is convinced that his body stinks and that, therefore, is the subject of ongoing rejection by others. In this sense, Japanese psychiatry has identified olfactory delusional syndrome with taijin-Kyofu-sho ("social anxiety"), a category similar to social phobia with the difference that in the first patients fear annoy or disturb others with supposedly despedido210 odor.

The "olfactory reference syndrome" is more common in young men and is characterized by the presence of intrinsic and unpleasant olfactory hallucinations, which appear in the foreground of the clinical picture and produce a reaction of shame, guilt and discomfort. It is usually accompanied by other symptoms except some of the depressed area, which are always secondary ("reactive") to the occurrence of hallucinations, ideas of reference or sensitive and systematized delusions rare side when the patient is in the company of others. The feeling of shame for detached body odor leads the patient to avoid social relations but the operation is not affected labor or other symptoms suggestive of a schizophrenic process. Pryse-Phillips says the olfactory reference syndrome may be included in the sensitive delusion of reference described in 1918 by Kretschmer211, provided that the experience of body odor is considered the "ultimate experience" leading to "shameful experience of failure, of moral inferiority. " Also, both the personality of these patients, which Kretschmer defined as "extraordinary emotional softness, weakness and vulnerability, and some ambition and stubbornness" - as "sensitive reaction" is similar to delirium reference. Regarding the nature of the olfactory reference syndrome, Pryse-Phillips for the reaction of shame to body odor is a "comprehensive development" to social rejection, regardless of whether real or hallucinated smell. Even the fear of odor release can be hallucinated olfactory perception, which the author represents an example of "psychogenic production" of a true hallucination.
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