treatment for panic attacks

treatment for panic attacks 

Causes

The cause is unknown, although genes may play a role. If one identical twin has the disorder, the other twin will also present the condition 40% of the time. However, panic disorder often occurs when there is no family history.

Panic disorder is twice as common in women than in men. Symptoms usually begin before age 25, but can occur at age 35. Although panic disorder may occur in children, is usually not diagnosed until they are older.

Symptoms

A crisis or panic attack starts suddenly and often peaks within 10 to 20 minutes. Some symptoms may continue for one hour or more. A panic attack can be confused with one heart.

Panic attacks may include anxiety about being in a situation where escape might be difficult (like being in a crowd or traveling in a car or bus).

A person with panic disorder often lives in fear of another attack and may be afraid of being alone or far from medical help.

People with panic disorder have at least four of the following symptoms during an attack:

Chest pain or discomfort

Dizziness or fainting

Fear of dying

Fear of losing control or impending doom

Feeling of choking

Feelings of separation

Feelings of unreality

Nausea or upset stomach

Numbness or tingling in hands, feet or face

Palpitations, rapid heart rate or pounding heartbeat

Sensation of shortness of breath or smothering

Sweating, chills or hot flashes

Trembling or shaking

Panic attacks can change the behavior and performance at home, work or school. People with this disorder often worry about the effects of your panic attacks.

People with panic disorder may have symptoms of:

Alcoholism

Depression

Drug

Panic attacks can not be predicted. At least in the early stages of the condition, trigger no attack begins. The memory of a past attack may trigger panic attacks.

Exams and Tests

Many people with panic disorder first seek treatment in the emergency room, because the panic attack feels like a heart attack.

The doctor will perform a physical exam, including a psychiatric evaluation.

Blood tests will be done. It must rule out other medical conditions before a diagnosis of panic disorder. Also must be considered drug-related disorders, because the symptoms can mimic panic attacks.

Treatment

The goal of therapy is to help you function well during everyday life. A combination of cognitive behavioral therapy (CBT) and medication works best.

Antidepressants called SSRIs (selective serotonin reuptake inhibitors) are the most commonly prescribed medications for panic disorder and include:

Fluoxetine (Prozac)

Sertraline (Zoloft)

Paroxetine (Paxil)

Other SSRIs

Other drugs that may be used include:

Other types of antidepressants, as inhibitors of norepinephrine reuptake inhibitors (SNRIs).

Anticonvulsants for severe cases.

Benzodiazepines, including diazepam (Valium), alprazolam (Xanax), clonazepam (Klonopin) and lorazepam (Ativan) can be used for a short time.

Monoamine oxidase inhibitors (MAOIs) are used only when other drugs do not work, because they can have serious side effects.

Your symptoms should improve slowly over a few weeks. Talk with your doctor if this does not happen. Do not stop taking your medication without telling your doctor.

Cognitive behavioral therapy helps you understand their behavior and how to change them. You should have 10 to 20 visits over many weeks. During therapy, you will learn how to:

Understanding and Managing distorted views of life stressors, such as the behavior of others or the facts of life.

Recognize and replace panic-causing thoughts and decrease the sense of helplessness.

Managing stress and relax when symptoms occur.

Imagine the things that cause anxiety, starting with the least feared. Practicing in a real life situation to help you overcome your fears.

The following may also help reduce the number or severity of panic attacks:

Eat at regular times.

Exercise regularly.

Get enough sleep.

Reduce or avoid caffeine, certain medications for colds and stimulants.

Expectations (prognosis)

Panic disorders can be long lasting and difficult to treat. It is possible that some people with this disorder is not cured with treatment, but most improvement with a combination of medication and behavioral therapy.

Complications

Substance abuse can occur when people who have panic attacks is to face your fear consume alcohol or illicit drugs.

People with panic disorder are more likely to live unemployed, to be less productive at work and have difficult personal relationships, including marital problems.

Agoraphobia is when fear of future panic attacks leads someone to avoid situations or places that are thought to cause the attacks. This can lead a person to put extreme restrictions on places where it goes or who is around. See: Panic disorder with agoraphobia

Anxiolytics dependence is a possible complication of treatment. Dependence involves needing a medication to function and to avoid withdrawal symptoms. It is not the same as addiction.

When to Contact a Medical Professional

Make an appointment with your doctor if panic attacks are interfering with your work, relationships or self-esteem.

Prevention

If you have panic attacks, avoid the following:

Alcohol

Stimulants such as caffeine and cocaine

These substances may trigger or worsen symptoms.

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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.

Kinesthetic HALLUCINATIONS

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.

Schizophrenia

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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Fobia Social and DSM and ICD classification systems diseases

diagnostic codes is essential for the collection of medical information.

The diagnosis coding facilitates data collection and retrieval and compilation of statistical information. Also often requires codes to facilitate communication of diagnostic data to third parties, including government agencies, private insurers and the Organization Salud.Los subtypes (some of which is encoded by the fifth character) and specifications are intended to increase the specificity. Within a diagnostic subgroups defined subtypes phenomenological mutually exclusive and are indicated in the criteria set by the words "specify the type." For example, delusional disorder includes different types according to the content of the delusions. Specifically, there are seven types: Erotomanic, grandiose, jealous, persecutory, somatic, mixed and unspecified. By contrast, the specifications are not intended to be mutually exclusive and are indicated in the set of criteria for the words "specify whether" (eg., In social phobia, the instructions say "Specify if: Generalized"). Specifications to define more homogeneous subgroups of individuals affected by a disorder, and that share certain characteristics (eg., major depressive disorder with melancholic). Although sometimes assigns fourth or fifth character to encode a subtype or a specification (eg., F00.01 Dementia Alzheimer type, with early onset, with hallucinations [290.12]) or severity (F32.0 Major depressive disorder , Single Episode, mild [296.21]), most of the subtypes and specifications listed in DSM-IV have not been coded according to the CIE-9-MC and are indicated only by including the specification subtype or after the name of the disorder (eg., social phobia, generalized). The ICD-10 system to encode a large part of subtypes and specifications. Specifications of gravity and cursor. Habitual manta, DSM-IV diagnosis applied to the subject's current manifestations and does not usually used to denote the previous diagnoses that individual has recovered. Once diagnosed, the following specifications are applicable indicator of severity and course: mild, moderate, severe, in partial remission, in full remission and history anterior. Las specifications mild, moderate and severe only be used when the condition meets in At present all the criteria. In deciding whether the presentation of the disorder has been described as mild, moderate or severe, the clinician should consider the number and intensity of the signs and symptoms of the disorder in question, and any irregularity in social or occupational functioning. In most disorders must use the following guidelines: Leveson few or no symptoms which exceed those required to make the diagnosis. Symptoms but do not lead to a slight impairment in social or symptoms or deterioration laboral. Moderato Existent works] located between "mild" and "severe." GraveSe detect several symptoms that exceed those required to make the diagnosis, or different symptoms are particularly severe symptoms or result in a significant impairment in social or laboral.En parcialCon remission before it met all the criteria for the disorder, but now only remain some of the symptoms or remission signos.En there totalYa any symptoms or signs of the disorder, but it is still relevant from a clinical point of view consider the disorder, for example, an individual with previous episodes of bipolar disorder has remained symptom free for the past three years, under treatment with lithium . After a period of time in complete remission, the clinician may consider that the subject is recovered and therefore encode no disorder as a current diagnosis. The differentiation in remission requires consideration of various factors, including the characteristic course of the disorder, the lapse of time since the last period pathological, the total duration of the disorder and the need for evaluation or treatment persistent profiláctico.Historia anteriorEn certain it may be useful to reconstruct the history of the criteria fulfilled by the disorder, even when the individual is currently recovered. These previous diagnosis of a mental disorder should be indicated using the specification above story (eg., Separation anxiety disorder, previous history, applicable to an individual with a history of separation anxiety disorder, which currently suffers no disorder now meets some or panic criteria). Several disorders have specific criteria to define them as mild, moderate and severe mental retardation, conduct disorder, manic episode and major depressive episode. Others have specific criteria to define partial remission and complete remission: manic, major depressive episode sustancias. Recidiva. En dependence clinical practice, it is common for the subjects, after a period of time that no longer met all the criteria of the disorder (eg., remissions or recoveries in whole or part), develop certain symptoms suggesting recurrence of the original condition, but nevertheless do not meet the requirements specified in the diagnostic criteria table. The best way to indicate the presence of these symptoms is a matter of clinical judgment. You have the following options: • If symptoms are thought to constitute a new episode of a recurrent disorder, the disorder can be diagnosed as current (or provisional) even before they have met all the criteria (eg., After meeting the criteria a major depressive episode during only 10 days instead of 14 days usually required). • Assuming that the symptoms are clinically significant but it is unclear which represent a recurrence of the original condition, you can use the unspecified category. • If opinion that the symptoms are not clinically significant, do not add any actual or provisional diagnosis, but may be logged "back story." Main diagnosis / reason for hospitalization consulta.Cuando in establishing a diagnosis over an individual, the principal diagnosis corresponds to that disorder, after studying the case, is considered primarily responsible for the income. In ambulatory care, when a subject is applied to more than one diagnosis, the reason for the visit is the disorder that warrants first ambulatory medical care received during the visit. In most cases the principal diagnosis or the reason for the visit are also the main subject of attention or tratamiento.Con is often difficult (and rather arbitrary) to determine which is the principal diagnosis or the reason for the consultation, especially in situations 'dual diagnosis' (a substance-related diagnosis, as dependence on amphetamines, accompanied by another diagnosis unrelated substances, such as schizophrenia). For example, it may not be clear what diagnosis should be considered "major" in the case of a person hospitalized for schizophrenia and amphetamine intoxication, since each of these disorders could have also contributed to the need for income and multiple diagnoses tratamiento.Los may be formulated as non-axial or multiaxial. When the principal diagnosis corresponds to an Axis I disorder, this is indicated by placing first. The other disorders are sorted according to the objective and therapeutic care. When a person has both Axis I diagnoses and axis II, it is assumed that the principal diagnosis or the reason for the visit will lie on Axis I unless the Axis II diagnosis is followed by the words "(principal diagnosis) "or" (during the consultation). "Diagnosis provisional.Cuando a clear presumption that all criteria for a disorder ultimately be fulfilled, but not enough information available to make a firm diagnosis in this case can provisional specification used. The clinician may indicate diagnostic uncertainty scoring "(provisional)" after diagnosis. For example, the subject seems to suffer a major depressive disorder, but it is possible to obtain an adequate history that establishes that all criteria are met. The term is also used in temporary situations in which the differential diagnosis depends solely on the duration of the disease. For example, a diagnosis of schizophreniform disorder requires less than 6 months and can be made only if assigned provisionally to have occurred before the unspecified category remisión.Utilización: Given the diversity of clinical presentations, it is impossible for the diagnostic nomenclature cover every possible situation. For this reason, each diagnostic class has at least one category and some unspecified classes include several categories including unspecified. There are four situations that may be appropriate to formulate a diagnosis not specified: • The presentation of the box coincides with the general guidelines specific mental disorder in the corresponding diagnostic class, but the symptoms do not meet the criteria for any of the specific disorders. This happens when the symptoms are below the diagnostic threshold of one's own specific disorders or when an atypical or mixed. • The presentation of the box is a symptom pattern that has not been included in the DSM-IV classification, but leads to clinically significant impairment or distress. Research criteria for any of these symptom patterns are included in Appendix B ("Criteria Sets and Axes Provided for Further Study forth"), in which case it is stated on page Appendix B includes criteria suggested research. • The etiology is uncertain (eg., if the condition is due to a medical condition, is induced by a substance, or is primary). • No opportunity for a full data collection (eg., in situations emergency) or the information is inconsistent or contradictory, but there is sufficient information for inclusion within a particular diagnostic class (eg., the clinician determines that the subject has psychotic symptoms, but not enough information to diagnose a specific psychotic disorder ).

Criteria often used: Criteria used to exclude other diagnoses and diagnoses suggest diferencialesLa most sets of criteria presented in this manual include exclusion criteria necessary to establish boundaries between different disorders and to clarify differential diagnoses. The various terms used to describe the exclusion criteria along the DSM-IV reflect the different types of possible relationships between disorders: • "It has never fulfilled criteria for ... "Used this exclusion criterion to define a hierarchy between different disorders throughout life. For example, a diagnosis of major depressive disorder and can not be made once had a manic episode, so it should be replaced with a diagnosis of bipolar disorder I. • "Does not meet criteria for ... "Used this exclusion criterion to establish a hierarchy between disorders (or subtypes) defined transversely. For example, specifying "with melancholic 'overrides' with atypical symptoms" to describe the current major depressive episode. • "Do not occur exclusively during the course of ... "This exclusion criterion prevents a disorder is diagnosed when symptomatic presentation occurs only during the course of another disorder. For example, not separately diagnosed dementia if only appears during a delirium; not separately conversion disorder if only appears for a somatization disorder; not separately diagnosed bulimia nervosa if only appears during episodes of anorexia nervosa . Typically, this exclusion is used in situations where the symptoms of a disorder are associated characteristics or a subset of the main symptoms of the disorder. The clinician should consider partial remission periods as part of the "course of another disorder." It should be noted that the diagnosis can be attributed excluded those occasions occur independently (eg., When the disorder is in remission exclusive). • "It is due to the direct physiological effects of a substance (eg ., a psychoactive substance, a medication) or a general medical condition "that is used to indicate exclusion criteria to be considered and ruled out general medical etiology or substance induced before diagnosing the disorder (eg., one can only be diagnosed MDD after discarding etiologies based substance abuse or a medical condition). • "Not better accounted for by ... "Used this exclusion criterion to indicate that the conditions mentioned in the criteria should be considered in the differential diagnosis of psychopathology in question and that in borderline cases will require clinical judgment to determine which disorder leads to diagnosis suitable. In these cases, you should consult the section "Differential Diagnosis" of entries for implicados.Existe disorders generally agreed that the DSM-IV should allow multiple diagnoses attributing those who meet clinical criteria for a DSM over -IV. There are three situations in which the aforementioned exclusion criteria help establish a diagnostic hierarchy (and thus avoid multiple diagnoses) or differential diagnostic considerations underline (and thus rule out multiple diagnoses): • When a mental disorder due to a general medical condition or a substance is responsible for the symptoms, diagnosis, priority is given to the corresponding primary disorder with similar symptoms (eg., mood disorder induced by cocaine is priority MDD). In such cases, the set of criteria for the primary disorder is an exclusion criterion includes the phrase "not due to the direct physiological effects of ... '. • When a more generalized disorder (e.g.. Schizophrenia) includes among its symptoms defining (or associated symptoms) which are symptoms of a disorder defining less widespread (eg., Dysthymic disorder), the set of less widespread disorder criteria appears one of the three following exclusion criteria, indicating that the disorder is diagnosed only more widespread, "has never fulfilled criteria for ... "," Does not meet criteria for ... "," does not occur exclusively during the course of ... ". • When there are limits particularly difficult differential diagnosis, included the phrase" not better accounted for by ... "To indicate that clinical judgment is required to determine which is most appropriate diagnosis. For example, panic disorder with agoraphobia include the criterion "not better accounted for by the presence of social phobia", and social phobia include the criterion "not better accounted for by the presence of panic disorder with agoraphobia 'recognizing the fact that in this case there is a boundary between the two conditions particularly difficult. In some cases both diagnoses are apropiados.Criterios for sustancias.Con use disorders is often difficult to determine whether the symptoms observed are induced by a substance, that is, whether it is the direct physiological consequence of intoxication or withdrawal substances, the use of a medication or toxin exposure. In an attempt to provide some help in making this determination, each of the substance use disorders were added the two criteria are reproduced below. It is understood that these criteria provide general guidelines, but also allow clinical judgment involved in determining whether symptoms are present or not better explained by the direct physiological effects of the substance. For further discussion of this topic, see "substance-induced mental disorders included in other sections of the manual" B. Based on the history, physical examination, or laboratory findings, evidence of (1) or (2): (1) symptoms appear within a substance intoxication or withdrawal, or for 1 month after (2) medication use is etiologically related to the trastorno.C. The disturbance is not better accounted for by the presence of a disorder that is not substance induced. Evidence that the symptoms are better explained by a disorder is not substance induced might include the following: the symptoms precede the onset of substance use (or medication use), the symptoms persist for a substantial period of time (p . example., about 1 month) after the cessation of acute withdrawal or severe intoxication, or are excessive in relation to what would be expected given the type, duration or volume of the substance used, or there is other evidence suggesting the existence of an independent non-induced disorder substances (eg., a history of recurrent non-substance). Criteria for a mental disorder due to a disease médicaEl aforementioned criterion is then necessary to establish the etiologic requirement each of the mental disorders due to a general medical condition (eg., mood disorder due to hypothyroidism). For a more extensive discussion of this topic, see "Mental Disorders Due to a General Medical Condition" The history, physical examination, or laboratory findings show that the disorder is the direct physiological consequence of a disease clinically significant médica.Criterios: The definition mental disorder consisting in the introduction of the DSM-IV requires that clinically significant impairment or distress. To underscore the importance of considering this fact, the criteria tables of most disorders include a clinical significance criterion (usually said "... cause clinically significant distress or impairment in social or occupational functioning, or other important areas of activity of the subject "). This approach helps to set the threshold for diagnosing a disorder in cases where symptomatic presentation (particularly in its milder forms) is not inherently pathological and can occur in individuals who would be inappropriate diagnosis of "mental disorder". To assess whether this criterion is met, especially in terms of activity, is inherently difficult clinical judgment. Often must rely on information about the subject's activity and family gathered from third parties (other than those from individual). Types of information that appear in the text of DSM-Ivel DSM-IV text describes each disorder under the following headings: "Diagnostic Features", "Subtypes and / or specifications", "typing procedure", "Associated Features and Disorders", "culture-bound symptoms, age and sex", "prevalence", "Course , "" familiar pattern "and" differential diagnosis. " If no information on one of these sections is not included in the text. In some cases, when several specific disorders a group of disorders share common characteristics, this information is included in the general information section clarifies diagnósticas.Esta grupo.Características diagnostic criteria and usually provides examples ilustrativos.Subtipos and / or make specification section provides brief definitions and analyzes concerning the subtypes and / or specifications of tipificación.Esta aplicables.Procedimiento section provides guidelines to register the name of the disorder and to select and record the ICD-10 diagnosis codes and ICD-9-CM adequate. It also includes instructions for applying any subtypes and / or specifications section asociados.Esta apropiados.Síntomas and disorders usually subdivided into three parts: • Descriptive characteristics and mental disorders asociadosEsta section includes certain clinical characteristics that are often associated with the disorder, but they are not considered essential to make the diagnosis. In some cases these features were proposed to be included as potential diagnostic criteria, but were not sufficiently sensitive or specific to be part of the final set of criteria. In this section also include other mental disorders associated with the disorder that is being analyzed. It is specified (when known) if these disorders precede, coincide or are consequences of the condition in question (eg. An alcohol-induced persisting dementia is a result of chronic alcohol dependence). When available, also included in this section information on predisposing factors and complications. • laboratorioEsta Findings section provides information about three types of laboratory findings that may be associated with the disorder: 1) those associated laboratory findings that are considered "diagnostic", for example, polysomnographic findings in some sleep disorders, 2) those associated laboratory findings that are not considered diagnostic of the disorder, but have been considered abnormal in groups disorder affected individuals compared with control subjects, eg ventricular volume computed tomography as a validator of the construct of schizophrenia, and 3) those laboratory findings that are associated with the complications of a disorder, such as electrolyte imbalances in individuals with anorexia nervosa. • examination findings asociadasEsta physical and medical conditions section includes information about symptoms collected in history, or findings observed during physical examination, which may have diagnostic significance but are not essential for diagnosis, such as dental erosion in bulimia nervosa. Also included are those disorders that are encoded outside the ICD chapter devoted to "mental and behavioral disorders", but which are associated with the disorder under study. As in the mental disorders, specified, if you know the type of association (eg., Precedes, coincides with, is a consequence of), for example, cirrhosis is a consequence of alcohol dependence. Symptoms depend on the culture, age and the clinical sexo.Esta section provides guidelines on different variations in the presentation of the disorder that can be attributed to the cultural, developmental stage (eg., infancy, childhood, adolescence, maturity, old age) or sex of the subject. This section also includes information on prevalence rates differentials related to sex, age and culture (eg., Sex ratio). Prevalencia.Esta section provides current data on prevalence and throughout life, incidence and risk throughout life. This data is provided in relation to different situations (eg., Community, primary care, outpatient mental health clinics and psychiatric inpatient facilities) when you have such información.Curso.Esta section describes the typical patterns of presentation and course of the condition over time. Contains information on the age of onset and the start mode (eg., Sudden or insidious) typical of the disorder; continuous versus episodic course: recurrent versus single episode, duration, characterizing the typical length of the disease and its episodes; and progression, which describes the general trend of the disorder over time (eg., stable, worsening, improvement). familiar.Esta Pattern section describes data on the frequency of the disorder among first-degree biological relatives compared with frequency in the general population. It also indicates other conditions that tend to occur more often in family members of those suffering from the disorder diferencial.Esta cuestión.Diagnóstico section discusses how to differentiate this disorder from others who have some presentation characteristics of DSM organization similares.Plan -IV: Diagnostic Classes principalesLos DSM-IV are grouped into 16 major diagnostic classes (eg., substance-related disorders, mood disorders, anxiety disorders) and an additional section called "Other problems that can be clinical care. "The first section is devoted to" Disorders in Infancy, Childhood, or Adolescence ". This division of the classification according to the age of onset of a disorder is raised only for convenience and is not absolute. Although the disorders included in this section often become apparent for the first time during childhood and adolescence, some individuals diagnosed with disorders that appear in the above section (eg., Attention deficit disorder with hyperactivity) can not be focus of clinical attention until adulthood. Furthermore, it is not unusual childhood or adolescence are the age of onset of various disorders included in other sections (eg., Major depressive disorder, schizophrenia, generalized anxiety disorder). Therefore, clinicians working primarily with children and adolescents should be familiar with the entire manual, and those who work primarily with adults should be familiar with this apartado.Las three sections - "Delirium, dementia and amnestic disorders and other trastornoscognoscitivos ',' Disorders mental due to a general medical condition "and" Substance-Related Disorders "- were grouped together in the DSM-III-R unit under the heading of 'organic mental syndromes and disorders." The term "organic mental disorder" is no longer used in the DSM-IV, since it implies incorrectly that other mental disorders that appear in the manual have no biological basis. As in the DSM-III-R, these sections are in the manual before the other disorders because of its priority in the differential diagnosis (eg., The causes of a depressed mood related substances should be ruled out before to make a diagnosis of major depressive disorder). To facilitate the differential diagnosis in these sections are complete lists of mental disorders due to medical conditions and substance-related disorders, while text and criteria for these disorders have been located in the diagnostic sections for disorders with which phenomenology share. For example, the text and criteria for the disorder of mood and substance-induced mood disorder due to general medical condition are included in "mood disorders." The organizing principle of all remaining sections (except adjustment disorder) disorders is grouped according to their shared phenomenological features to facilitate the differential diagnosis. The section "Adjustment Disorders" is organized differently as these disorders have been grouped according to their common etiology (eg., Maladaptive response to stress). Therefore, adjustment disorders include a wide variety of heterogeneous clinical presentations (eg., Adjustment disorder with depressed mood, adjustment disorder with anxiety, adjustment disorder with disturbance of conduct). Finally, the DSM-IV includes a section "Other issues that may be of clinical care." Included in this digital version of the DSM-IV, in addition, the following appendices: Criteria Sets and Axes Provided for studies posteriores.Este appendix contains a number of proposals suggested for possible inclusion in the DSM-IV. Was provided a series of short texts and research criteria related to the following disorders: postconcussional disorder, mild neurocognitive disorder, caffeine withdrawal, pospsicótico depressive disorder in schizophrenia, deteriorating simple, premenstrual dysphoric disorder, minor depressive disorder, depressive disorder recurrent brief, mixed anxiety depressive disorder, factitious disorder by proxy, dissociative trance disorder, binge eating disorder, depressive personality disorder, disorder passive-aggressive personality, neuroleptic-induced parkinsonism, neuroleptic malignant syndrome, acute dystonia induced neuroleptics, neuroleptic-induced acute akathisia, neuroleptic-induced tardive dyskinesia and medication-induced postural tremor. Furthermore, some descriptions are included schizophrenia dimensional alternatives and alternative Criterion B dysthymic disorder. Finally, this is indicated proposed three axes: defense mechanisms Scale, Global Assessment Scale relational activity (GARF) Scale and evaluation of social and labor (SOFAS). Técnicos.Este Glossary appendix contains a glossary definitions of selected terms to help users of the manual in implementing criterios.Indice tables of DSM-IV.Este modifications appendix lists the major changes, from the DSM-III-R, have been included in the terms and categories of DSM-IV.Indice alphabetical diagnoses and DSM-IV codes (ICD-10). This appendix lists the DSM-IV (with ICD-10) in alphabetical order. It has been included to facilitate the selection of diagnostic codes and numerical diagnósticos.Indice DSM-IV codes (ICD-10). This appendix lists the DSM-IV (with ICD-10) in numerical order according to code. It has been included to facilitate the registration of terms diagnósticos.Guía for cultural formulation and glossary cultura.Este bound syndromes appendix is ​​divided into two sections. The first provides an outline for cultural formulation to assist the clinician to systematically assess and report regarding the impact of cultural context on a particular individual. The second section is a glossary of bound syndromes alphabetical subject cultura.Indice

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DOUBLE hallucination and other phenomena

DOUBLE hallucination and other phenomena 

One of the best known types of hallucination is called "dual phenomenon" (also called autoscopy, heautoscopia, Doppelganger, etc..). The autoscopy (literally see himself) is defined as the visual experience in which the subject sees his picture in external space (as if reflected in a mirror) from their own cuerpo75. Vision may be brief or persistent, the whole person or parts of it, with a normal consistency or clear and accompanied by an emotional response. However, little is known about the natural history, clinical presentation, the meaning and etiology of this experience is not even clear that should always be considered a hallucination.

This phenomenon has been observed since antiquity. Aristotle, in his work Meteorological, and told of a man who every time he went for a walk persistently saw his own image walking towards él76. The consideration of the phenomenon as abnormal or pathological depends on cultural beliefs about the limits of self and the ability to view the image itself. So, this experience is in the mythology of the death and resurrection of some Asian tribes and among Aboriginal australianos77. In Western culture fads and secular beliefs have been important since in European folklore autoscópicas experiences were considered a harbinger of death inminente78. In the nineteenth century romantic literature there are descriptions of autoscopy and similar experiences in the works of Jean Paul Richter (Hesperus), Gabriele d'Annunzio (Notturno), Oscar Wilde (The Picture of Dorian Gray), Guy de Maupassant (The Horla ), Edgar Allan Poe (William Wilson) and Fyodor Dostoevsky (Twice). Other writers like Alfred de Musset, Robert Stevenson, Gerard de Nerval, James Hogg or own Maupassant and Poe's hallucinatory experiences doble76 suffered. In the nineteenth century the symptom was well known and was called variously 3, 75 Brierre of Boismont called deuteroscopie; Jean Paul Richter doppelganger used the term to refer to the 'bi'; autoscopy (Féré; Lemaitre; Sollier) was used in the early twentieth century, but failed to find the correct perception of the subject itself was replaced by heautoscopia (Menninger-Lerchenthal; L'Hermitte; Hecaen and Ajuriaguerra). The terms hallucination speculaire (Féré) and Spiegelphantom (Conrad) not jelled because the perception of the subject pointed itself. Dening and Berrios75 considered more appropriate to reserve the term autoscopy for alterations of visual perception in which subjects see their own image in the external space from his own physical body.

Autoscópicos phenomena have been described in neurological diseases such as epilepsy, migraine, tumors, strokes, head injuries and infecciones75, 79, 80, 81, 82, 83 and psychiatric disorders such as schizophrenia, depression, anxiety, depersonalization, and dissociative states identificación75 false syndromes, 78, 79, 84, 85, 86, 87.

It has been suggested that the autoscopy could arise from the convergence of several variables, such as gender, personality traits, psychiatric illness and / or neurological, and dissociative states whose depletion interaction could overcome the normal inhibition lobe activity temporal73.

Brugger82 group, 88, 89 has proposed a classification of autoscópicos phenomena including six types:

1. Sense of presence: in this phenomenon the "double somatestésico ghost" is "sense" but not seen (similar to phantom limb phenomenon) 90. It also goes by the names of Anwesenheit91, next falsa92 consciousness and somestésico93 doppelgänger.

2. Hallucination autoscopic: visual hallucination would double itself dicha94. That is, the double would be seen only from the body itself, lacking any component somatestésico. Originally called "hallucinations mirror" 95, 96.

3. Heautoscopia ghost or double vision and somatestésico: implies the existence of two selves (observer and observed), although recently described the experience heautoscopia poliópica where the existence of multiple dobles97. Also called self85 autoalucinación98 and hallucination. In this case the visual aspects are predominant and twice, seen also from the body is described as pale, hazy, transparent or ghostly. The most important is the psychological feeling of affinity towards the second self, "meaning" and physically recognized as "other me" even when the visual characteristics do not match their own (heautoscopia dissimilar) 94.

4. The out of body experience. This term, from the para-psychology, replaced previous expressions of the world of para-normal phenomena as "astral projection," "ectosomática experience" or "externalization of sensibility" and was related to statements such as "bi" ( the supposed ability of some people to be in two places at once), the "astral bodies" (hypothetically body consisting of a "light stuff") or experiences near the muerte99, 100. In medical and psychological literature have used other terms like "pseudo autoscopia", "ego trip", "floating syndrome experience," "hallucinations of physical duality" and "split visuo-vestibular somatosensory body image» 82. The phenomenon is the perception of oneself from the outside, ie from a visio-spatial parasomática unlike other autoscópicos phenomena are experienced within the corporate limits and the double is perceived from a visio-spatial física101. In OBE rarely used the term "double", and the main feature is the apparent remoteness of body awareness, which is seen or "seen" in another spatial point. Recently, it has been explained as poor integration of visual, tactile and proprioceptive body awareness with information relating to personal space and extrapersonal101, 102, 103, 104.

5. Heautoscopia negative: in this case the subject is not himself when his image reflected in a mirror. In most cases, is accompanied aschématie or loss of consciousness itself cuerpo105, 106. Some authors have proposed replacing the term by 'asomatoscopia »81, 107. Guy de Maupassant described this phenomenon in The Horla and E. T. A. Hoffman in his fairy tales.

6. In the internal heautoscopia internal organs are visually hallucinated extracorporeal space. This rare phenomenon, also called "organic self-representation," was described by several French writers of the early XX108, 109.

From neurology, autoscópicos phenomena have been related to the failure of the integration of proprioceptive, tactile and visual relative to body (multisensory disintegration in personal space) with vestibular dysfunction causing further disintegration among staff spaces (vestibular) and extrapersonal (visual). These disintegrations (personal personal-extrapersonal) are due to "paroxysmal brain dysfunction" in the temporo-parietal101 intersection, 102, 103. Moreover, it has been proposed that these experiences and the phantom limb phenomenon related to central representation of bodily self and suggest that the concept of 'neuromatrix "or" neuromatrix »* could help explicarlos82, 110. Specifically, there would be a "dissociation of neuromatrix" consisting temporal dissociation between the visual components and the neuromatrix somestésicos or between different subcomponents somatestésico field (for example, between the kinesthetic and tactile impressions).

* Melzack postulates that in the central nervous system there is a representation of body image or "neuromatrix 'which modulate cortical activities (affective and cognitive) with somatosensory afferents, visceral, nociceptive, autonomic, immune and endocrine generating pain perception. The neuromatrix is ​​a neural network that receives input and generates a "neurofirma" ("neurosignature") or print one for each person. Pathways involved there would be three: the first is sensitive and passes from the thalamus to the somatosensory cortex, the second is from the reticular formation to the limbic system and the third involves the parietal lobe where it generates the perception of the "self."

Lilliputian hallucinations

These complex visual hallucinations were described in 1834 by Leuret in the context of místicas111 experiences. In 1847, Sauvet used the term "midget" to refer to the vision of small beings that he himself experienced after poisoning by inhalation éter112 voluntary. They consist of the vision of "little people, men or women of diminutive height, which may be accompanied by small animals and objects provided in size" 113, 114. Hallucinations are usually multiple and people move and wear colored clothes. Occasionally represent a small puppet theater with miniature scenes and the patient hears these people speak in a "Lilliputian tone." Leroy said that unlike other visual hallucinations, the Lilliputians are accompanied by a pleasant mood and the patient attends funny representation of the world in miniature. Such hallucinations has little diagnostic value and have been described mainly in alcoholism and other poisoning as cocaine, cannabis, atropine, chloral and ether, and brain tumors, infections, vascular injury, dementia, epilepsy and hypnagogic states. In psychiatry have been described in schizophrenia and states disociativos115, 116.

Hypnologic hallucinations and hypnopompic

                                                                              

Hypnagogic hallucinations consist vivid perceptual experiences occurring at sleep onset, while hypnopompic happen to awaken it. For Hamilton, hypnopompic hallucinations, sensu stricto, is that, from sleep, remain when opening ojos117. The first systematic description of these phenomena was made in 1846 that Baillarger considered psychosensorial hallucinations. The term "hypnagogic"-of Hyno (sleep) and agogos (induced) - Maury introduced him in 1848 to designate the illusions that he experienced in sleepiness before sueño118, while the term "hypnopompic" first used it Myer time in 1918 to describe these phenomena during the transition between sleep and vigilia119. Hypnagogic and hypnopompic hallucinations are characteristic, and relatively frequent in narcolepsia120, but can also occur in normal subjects so sometimes hallucinations have been called physiological, and other psychological disorders such as depression, anxiety states , psychosis and intoxication. These are generally characterized by the perception of images (more rarely sounds) imposed in consciousness without the will of the subject although it recognizes the failure of the phenomenon, but at the same time experiencing them or, more often, when the state recovers normal waking. The duration varies from a few seconds to fifteen minutes, depending on the persistence of sleepiness. Fever or low vision can trigger hallucinations in subjects predispuestos121. The content of hallucinations is striking: usually bright spots of vivid colors or shapes that transform into shapes or complex images like human figures, faces, animals and landscapes of great beauty or adopt complex shapes from scratch. The images can be static or mobile and vividness and richness of experience outweigh any real phenomenon. Unlike what happens in deep sleep, the subject observes the action as a spectator without a plot that looks directly involved. The emotional response to the images can be neutral, pleasant, or terrorífica35 fascinating.

Musical hallucinations

Musical hallucinations are rare and are at the crossroads of otology practice, neurological and psiquiátrica122, 123, 124. Being so rare there is no commonly accepted theory on its diagnostic value, classification and path physiological mechanisms. Usually refers to hearing songs or melodies, although some authors consider this restrictive definition since music also includes harmonies, rhythm and timbres. This distinction is important because if the musical hallucinations causally related to specific brain locations is essential to know if the processing of information relating to the melody, harmony, rhythm or timbre locus occurs on a common brain. Also more likely to describe a musician as "music" more complex hallucinatory experiences that a person without musical training, so communication of musical hallucinations will be influenced by the musical knowledge of the patient. This would also influence the location of brain injury because the representation of musical information changes nondominant hemisphere dominant learning to musical125.

The history of musical hallucinations began in 1880s. Although authors such as Esquirol, Griesinger Baillarger or reports of patients had deaf hearing voices or music, psychiatrists are less interested in these phenomena that ENT. For example, stood Erhard126 various locations of these "subjective auditory sensations' sense of rhythm or pulsation in the internal carotid, the whispers in the hall, the songs or music in the cochlea, and tinnitus in the acoustic nerve. To Régis127, musical hallucinations are the result of positive and negative changes in sensory pathways: the first (eg, tinnitus) resulted in a sound that served as the point where crystallize musical hallucination, negative changes (eg deafness) helped create a state of deafferentation. Régis was forced to introduce other variables such as age or personality traits to explain why these hallucinations are so infrequent, although deafness and tinnitus are so common. During this same period, organic and psychological hypotheses proposed to explain the origin of such hallucinations. For example, unilateral musical hallucinations were considered organic aetiology (peripheral), although peripheral lesion could not alone explain the laterality of hallucination and suggest that there is also a cortical lesion. For insight Régis presence would serve to distinguish musical hallucinations of psychotic organic (functional). For example, Claude and Ey128 described the so-called "organic hallucinosis syndrome"-in which included musical hallucinations-and that is not related to psychotic hallucinations. At present there is still debate about the origin exclusively otologic or also could occur from neurológica124 pathology, 129, 130, 131.

In the history of music known several examples of composers who suffered hallucinations musicales132. The Czech Smetana, who probably suffered meningovascular neurosyphilis, persistently experienced hearing a high-pitched musical note he included in his String Quartet. The best known case is that of composer Robert Schumann, who for years suffered musical hallucinations from single notes to chords and melodies, which were reflected in works like the Kreisleriana, the Violin Concerto and the Symphony Spring.

Saba and Keshavan133 indicate that musical hallucinations are variable and complex phenomenon, and collected three causal mechanisms:

1. By "neuronal irritation" (excitatory phenomenon).

2. By "perceptual release" (release phenomenon).

3. By "musical memories parasites', ie, some memories (eg a song) are never 'unlearned', maintaining therefore fixed and independent presence in memory so that they become a regular experience.

Musical hallucinations have been described in different situations clínicas40, 122, 124, 134: hearing loss, brain damage from space-occupying processes to epilepsy and encephalitis vascular processes; psychoactive substance use and psychiatric disorders.

Depending on the etiology hallucinatory experience may vary in some respects as the form of onset (acute or insidious), the familiarity of what is heard, the type (instrumental, vocal or both) and genre, the origin of the perceived (in or outside the head), the location (right, left or bilateral), the sole presentation accompanied by other symptoms or impaired sensory perception or other psychiatric symptoms, the experience (pleasant, unpleasant or neutral) and the degree of insight.

To Berrios122, musical hallucinations are more common in women, in old age, with deafness and brain injuries most common causes. They tend to be persistent and continuous, but may be retained fragment and like a broken record. The most common form of hallucinations are either a cappella songs or instruments, the music is very common religious or patriotic hymns.

Regarding the specifics of hallucination in ear pathology hallucinations often accompany progressive onset and otherwise simple acoustic hallucination. Due to a brain process establishing abruptly, not accompanied by other hallucinations and insight remains on experience. Furthermore, it appears that no longer affect the hemisphere dominante135. The latter is very important because it suggests that the nondominant hemisphere plays an important role in the development of musical phenomena in patients with brain injury from tumors, strokes or epileptic foci. This finding is consistent with what is known of the relationship of music and the brain. It also suggests a dissociation between musical hallucinations and mechanisms related to verbal hallucinations in schizophrenia associated with the dominant hemisphere. Finally, the musical hallucinations in psychiatric disorders appear more frequently reported in depression, may be associated with other auditory hallucinations, visual and tactile, and there is usually no insight on them.
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