CPD CONTINUING

PROFESSIONAL
DEVELOPMENT

Hallucinations: insights and

supportive first care
NS827 Price B (2016) Hallucinations: insights and supportive first care. Nursing Standard. 30, 21, 49-58.
Date of submission: June 9 2015; date of acceptance: October 16 2015.

Abstract Aims and intended learning outcomes

Nurses working in a range of clinical settings may encounter patients
who report experiencing hallucinations, whether auditory, visual or any
other form. This article, which has been written for nurses working
in general practice rather than mental health practice, clarifies the
differences between hallucinations and delusions and explains that both
symptoms are often experienced together in mental illness. The possible
causes of hallucinations are summarised and the advice that should be
given to patients is discussed. Although patients might manage their
hallucinations by creating narratives to explain what is happening to them
and to find ways of representing their experience to others, diagnosis and
treatment of underlying conditions are important too. The article outlines
precepts that can guide the nurses response to a patient presenting with
hallucinations for the first time.
Author
Bob PriceHealthcare education and practice development consultant,
Surrey, England.
Correspondence to: altanprice@sky.com
Keywords
bipolar disorder, delusions, hallucinations, mental health, psychoses,
schizophrenia
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The aim of this article is to help you to review
what hallucinations are, identify the common
conditions or circumstances in which they
might occur, and recommend precepts
regarding how best to respond to patients
who report hallucinations. No assumptions
are made that the reader has previous mental
healthcare training.
Reference is made to schizophrenia, one
diagnosis that is commonly associated
with hallucinations, and one possible
explanation of how hallucinations develop
in schizophrenia is outlined. It should
be noted, however, that explanations of
psychoses are often contested, and best
treatments for the condition are debated.
Antipsychotic medications, transcranial
magnetic stimulation and talking therapies
have all been used in an effort to help patients
manage schizophrenia (Lieberman et al 2013,
Subramanian et al 2013). After reading this
article and completing the time out activities
you should be able to:
Clarify the differences between hallucinations
and delusions.
List the common conditions that can cause
hallucinations.
Describe the stages that an individual might
go through as they learn to cope with their
hallucinations (for convenience, the article
refers to patients, but it is not assumed that
all individuals reporting hallucinations are
necessarily ill).
Outline one explanatory model of why
hallucinations might occur in schizophrenia.
Outline initiatives designed to help people
interpret and cope with hallucinations at
a personal level.
State four precepts for working with
a patient who reports hallucinations for
the first time.

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CPD mental health
Introduction
Before the benefit of scientific insight, there were
some fanciful explanations of hallucinations.
The individual experiencing hallucinations
might have been considered mentally ill (mad,
in past parlance), a shamen, witchdoctor,
witch or spiritual medium, or as someone
possessed by a malevolent spirit. Subsequently,
scientific investigation has sometimes linked
hallucinations with disordered neurological
function, particularly that associated with
chemical imbalances in the brain (Hallak
et al 2013, Howe and Murray 2014). However,
as explained in this article, hallucinations
might also be associated with many other
causes and may occur when there is no obvious
neurological disorder.
Hallucinations are often frightening for
individuals and they can be startling for nurses
who encounter patients experiencing them.
One question a nurse might ask is how should I
respond if someone confides that they are seeing
or hearing strange things?. Hallucinations,
like pain, might be symptomatic of underlying
problems that require treatment. However,
some hallucinations, such as hearing voices,
can be experienced by individuals who have
no discernible underlying pathology and who
must find ways to cope with their experience
over time (Beavon et al 2011). Verdoux and
Van Os (2002) explained there is a continuum
of hallucination experience; most individuals
experience a hallucination at some time, for
instance in association with sleep deprivation
or on waking or falling asleep, ranging to those
who are significantly disabled by repetitive and
distressing psychotic episodes.
As in pain management, nurses should attend
to patients reported concerns, help them to
understand what is happening and find better
ways to cope if the problem persists. Patients
should be helped to deal with symptoms as
well as to use treatments to address underlying
illness. When hallucinations are associated with
1 Read the case disordered reasoning, delusions and changes
studies in Box 1 and in the individuals ability to sustain social
think about how you interaction, and where there are thoughts about
might have reacted if inflicting harm on oneself or others, a prompt
you had encountered referral to specialist mental health services is
these situations. What is required (National Institute for Health and
at issue when you are Care Excellence (NICE) 2013, 2014).
first told something Although researchers have attempted to
so unusual? In these link specific types of hallucinations to
accounts, identify the particular neurological deficits, particularly
delusions and explain in schizophrenia (Teeple et al 2009, Hallak
how they relate to the et al 2013), the explanation of hallucinations in
reported hallucinations. purely neurological terms remains incomplete at
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best (Kahn and Keefe 2013). In a philosophical
debate on what we know about the mind,
Mlodinow (2011) conceded that science
struggles to explain how something physical
(the brain) can produce personal experience.
The mind cannot be completely explained in
terms of brain function. Hallucinations are both
sensations relating to something that is not there
and a form of ideation; the sensations felt, seen,
smelled, tasted or heard are assigned a meaning.
Hallucinations and delusions
Hallucinations are sensations experienced
in the absence of external stimuli that can
affect one or more of the senses: hearing,
sight, touch, smell and taste (Sharma 2014).
Delusions are defined as false and fixed beliefs
that do not relate to reality (Sharma 2014).
Delusions associated with schizophrenia
are further defined as beliefs that are not
amenable to change in the light of available
and conflicting evidence and are misaligned
with cultural ways of interpreting experience
(American Psychiatric Association 2013).
Delusions linked to mental illness can take
different forms, including the persecutory and
grandiose, the latter when the patient believes
they are someone that they are not (American
Psychiatric Association 2013). Delusions may
become embedded as the individual struggles
to make sense of their hallucinations. Three
brief case studies of people who have reported
hallucinations to me during the course of my
clinical practice are provided in Box 1.
Complete time out activity 1
In each of the cases summarised in Box 1, the
person experiencing the hallucination has also
reported a delusion. Gavins hallucinations
were auditory and threatening, as is common
in schizophrenia, and they made him feel
anxious (Cockburn and Cockburn 2011).
Choong et al (2007) reported that 75% of
people with schizophrenia experience auditory
hallucinations, which are also relatively
common in bipolar disorder (20-50%).
Although the voices did not instruct Gavin to
harm himself or others, they disparaged him.
Significantly, Gavin needed to feel special,
skilful and important. He had grown up with
more successful older siblings. The delusion that
was paired with the auditory hallucination was
that threatening messages were directed at
him via the local radio station. Gavin presented
with what have been described as both positive
and negative symptoms of schizophrenia
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(Cuesta et al 2007). The positive or hard
symptoms were hallucinations and associated
delusions, although disorganised reasoning
and disrupted language were not prominent
features. The negative symptoms included a lack
of volition Gavin felt powerless to respond to
his situation and extreme discomfort in the
situation he felt he was facing.
Marcuss hallucinations were visual and
consisted of seeing an eye on the forehead of
one of the nurses monitoring him. He had a
well-developed and quite complex delusion one
that centred on his feared mother who was now
dead, but who he believed was still able to attack
him mentally. Jordaan et al (2009) explained
that individuals experiencing alcohol-related
psychoses typically exhibit fewer of the negative
symptoms associated with schizophrenia and
often show greater insight into their condition.
In this instance, however, Marcus had been used
to consuming a combination of alcohol and
other drugs, which made it difficult for him to
characterise his illness.
Annies hallucinations were also auditory,
but quite different in character to Gavins.
The voices were comforting, amusing and
informative; they gossiped and allowed Annie
to be part of the dialogue. Sometimes, in
private, she talked back to the voices. Her
belief was that the voices emanated from inside
her chest rather than her head. She could not
explain what the voices were, but she had felt
reassured over time that they meant her no
harm and could be lived with, provided that
you didnt say too much about them as people
might think you were strange.
Importantly, all the hallucinations described
in Box 1 were experienced vividly and felt to be
real by the person. Each of the hallucinations
challenged the individual to answer difficult
questions. What did the hallucinations signify?
What did the hallucinations say about me if
others did not routinely experience these things?
Although hallucinations reported to nurses
might seem foolish, the level of concern or
distress expressed by the patient means that the
nurse has to pause and consider their response.
If care is to be dignified, then respect must be
shown for the patients experiences (Somerville
2014). What the patient reports about their
hallucinations and delusions forms an
important part of the patient history. Learning
about patient experience, without confirming
the patients delusion, is therefore important.
The types of hallucinations experienced by
patients who have psychoses, their frequency
and extent are believed to be associated with
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a complex mix of factors, including chemical
functioning in the brain and psychosocial
experiences while growing up. Bauer et al
(2011) studied 1,080 patients diagnosed
with schizophrenia from seven countries
and reported that visual hallucinations
were more common in Africa and auditory
hallucinations were more common in Austria
and Georgia. The types of hallucinations
seemed to be culturally mediated and linked
BOX 1
Examples of hallucinations reported to the author
Case study 1
Gavin* was a teenager who shared a holiday with us. One evening in the
campsite bar, Gavin confided to me that he was a marked man and regularly
received threats over the local radio station, indicating that he would be
assassinated by the Russian secret service. At first I was not sure that I
had heard him correctly. His report was delivered with conviction, and with
evident discomfort. I asked him to repeat what he said and he explained that
he had been monitoring foreign agent movements for MI5 for some time. He
did not know how the Russians had infiltrated the local radio station, but the
messages he received over the air were always brooding, indicating that they
knew what he did and where he lived. After the holiday, I consulted his parents
who thought he had been more agitated and anxious recently. Gavin consulted
his doctor, he was referred for psychological assessment and a diagnosis of
schizophrenia was subsequently made.
Case study 2
Marcus* was in hospital with a chest infection and was receiving intravenous
antibiotics. He was dependent on alcohol and drugs. One day, while I was
changing his intravenous infusion, he informed me the nurse who saw him
earlier that shift was watching him with her middle eye. He insisted some
people had a middle eye in the centre of their forehead and that this was used
to monitor the likes of me. The nurses middle eye was not always open and
few others could see it, but he wondered what I had noticed. I explained that
I hadnt noticed anything out of the ordinary. Wishing to convince me that he
was being persecuted he presented his wrists to me. Could I feel a pulse in
his left wrist? Yes, I could. Could I feel a pulse in his right wrist? Yes, I could.
He explained that this signified that all was well for now. His mother, who had
hated him, lived in a space ship and she had tried to use mental powers to
turn off one or both of his hearts (he had two pulses). She had also directed
the nurse with a middle eye to monitor him. I reported my conversation with
Marcus to the doctor and further history taking followed. It was concluded
that Marcus experienced visual hallucinations and delusions associated with
drug and alcohol withdrawal while in hospital.
Case study 3
I met Annie* while running a workshop that she was attending in a
professional capacity. She confided she trusted me because I dealt with
psychological matters and told me she heard voices, cheerful ruminative voices
from people of her age and background whom she did not know. She called the
voices the gossipers. The voices were never threatening or accusatory, they
never told her to do things and in many ways they seemed good company. The
voices did not impede the support that she gave to patients. I asked where the
voices came from and she explained that they were in her chest, but sounded
up through her head. They werent there all the time, but did appear if she was
tired or fed up.
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CPD mental health
to habitual beliefs. A belief in ancestors, for
example, might predispose the patient with
schizophrenia to develop hallucinations about
dead relatives. Delusions associated with
the hallucination might also be culturally
mediated; the patient might believe that a
dead relative is controlling their mind.
Bivin et al (2014) conducted 52 interviews
with patients diagnosed with schizophrenia
and noted the wide variation in the experience
of auditory hallucinations. Half of the
respondents heard voices for a few minutes
each day, but nearly 70% of respondents
reported hearing multiple voices, talking at
the same time. Of the respondents, 88% said
that they experienced auditory hallucinations
more often if they were alone, which seemed
much more frightening. Half of the patients
interviewed believed that their antipsychotic
medication had no effect on the voices, neither
abating the experience nor significantly
changing what was heard. At the time of
interview, however, only 11% of respondents
2 Reflect on how said that their voices were hostile, although it is
you might feel if you possible that this figure might have been higher
started to hear voices before treatment commenced.
for the first time and Complete time out activity 2
could not attribute
them to external stimuli.
What would it feel like Origins of hallucinations
to think that these The Hearing Voices Network (2016), a registered
voices are coming from support group for individuals who experience
inside you, or from both auditory and other types of hallucination,
someone or something reminds us that auditory hallucinations are
you cannot see? Imagine comparatively common. Voices can be
how it feels to realise comforting, reassuring and convivial, as in the
that no one else seems case of Annie (Box 1). The experience can be
to be reacting to the more common during bereavement when a
voices that you hear. deceased loved one appears to continue talking
to us and might even appear to us in visual form.
3 Revisit your Some individuals have heard voices all of their
responses to Time out lives and have never been diagnosed with an
activity 1 and decide underlying illness, yet function well in society.
whether receiving Spiritual beliefs can culturally attune
reports of hallucinations individuals to experience both visual and
from a patient who auditory hallucinations while they are dying.
is dying might seem There might be an expectation that those
different to you. Would who have already died appear to welcome
you be more inclined the individual as death becomes imminent.
to affirm the patients Devery et al (2015) observed that deathbed
experiences, accepting hallucinations are common and that
these as part of their patients who are dying are reassured by the
beliefs about what hallucinations, which help them to believe there
happens as a person dies? is an afterlife. Fountain and Kellehear (2012)
Is this affected by your also reported that hallucinations are common
own spiritual beliefs? among patients who are dying, although
it was less clear whether this is prompted
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more by cultural expectations (a form of
auto-suggestion associated with expectations
of death) or whether it has a physical cause
as the brain experiences varying degrees of
hypoxia or from the effects of opioid analgesia.
Complete time out activity 3
Visual hallucinations can be associated with
a number of different neurological diseases.
They are commonly experienced in late-stage
Parkinsons disease and in late-stage dementia.
Patients with dementia can misconstrue what
they see, for example identifying faces in
patterns on wallpaper or on curtains. Such
patients might have difficulty processing
complex visual patterns. The Alzheimers
Society (2012) factsheet on sight, perception
and hallucinations in dementia assists carers in
understanding that this problem is distinct from
psychosis. Feelings of persecution, however, are
associated with deterioration in memory and
are made worse when carers respond to them
with frustration. Van der Linde et al (2014)
included hallucinations among the possible
psychological symptoms that patients with
dementia might encounter and identified these
hallucinations as a possible cause of subsequent
challenging behaviour. Severely agitated
individuals with dementia might be responding
to an increased incidence of hallucinations,
although for ethical and practical reasons it
is difficult for researchers to obtain clear and
incontrovertible data in this area. Parkinsons
UK (2013) advised patients that hallucinations
and delusions are a late-stage feature of
Parkinsons disease and can be associated
with prolonged use of symptom-controlling
medication.
Patients who experience loss of eyesight
associated with macular degeneration
frequently report visual hallucinations (Charles
Bonnet syndrome), which are caused by the
brain compensating for lost input from the
damaged eyes (Schneider and Schneider 2013).
The visual hallucinations associated with
Charles Bonnet syndrome can include abstract,
shape-shifting visual images as well as familiar
objects and people. The Royal National
Institute for the Blind (2015) cautioned that
these hallucinations can last up to five years
and that some simple eye exercises moving the
eyes left and right can help the patient to stop
the hallucinations.
Hallucinations are also experienced by
patients with delirium. Patients who have
spent significant time in intensive care settings,
especially if they have undergone artificial
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ventilation, can hallucinate (Elliot 2014).
The physical effects of treatment and the
disorientation of an environment where normal
body rhythms are interrupted and there is less
personal control, can cause the individual to
become agitated (Roberts and Chaboyer 2004).
It is especially important to orient patients as
they are weaned off artificial ventilation and
to work with relatives to remind the patient of
what has been happening, where they are and
what care is being delivered. Hallucinations
in these contexts are likely to be a temporary
problem and one that the patient might or
might not remember as they recover from their
injury or illness.
Long-lasting problems with hallucinations
can occur as a result of drug or alcohol misuse.
Rainier (2014) reported that hallucinations
may be problematic in patients experiencing
alcohol withdrawal and that physical restraint
might sometimes be required. However, the
goal should be to reduce the need for physical
restraint of patients; briefing patients before
withdrawal treatment might help them to
deal with hallucinations should these occur.
Cannabis and designer drugs (synthetic
analogs of illegal drugs) have been associated
with hallucinations and some of the newer
cannabinoids have been linked with persistent
hallucinations that continue after the drug has
been withdrawn (Brewer and Collins 2014).
Because of the speed at which new street drugs
are produced and distributed, it is difficult to
profile the hallucinations and delusions that
can be associated with these substances.
Complete time out activity 4
Psychoses
Classically, hallucinations are associated
with mental illness, particularly psychoses,
schizophrenia and bipolar disorder. Patients are
advised by NHS Choices (2014) that psychosis
is a mental health problem that causes people
to perceive and interpret things differently from
those around them. In bipolar disorder there
are significant shifts in mood state, whereas in
schizophrenia, the interpretation of experiences
becomes disordered and the patient lacks
volition to engage with others. Schizophrenia
can present with relapses (crises when reasoning
is significantly disordered) and recovery periods
when the patient is better able to reflect on their
experiences. Psychoses have been classified
in different ways, but for the purposes of this
article it is important that the nurse recognises
the main symptoms that mandate a prompt
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referral for further mental health assessment.
These include (Waters and Stephane 2015):
Hallucinations (which can seem threatening
with the patient feeling persecuted).
Delusions (about self and others).
Significant shifts in mood state (swinging
between periods of mania and depression).
Disordered ideation, difficulties in forming
clear lines of thought and, in association
with this, verbal expression that makes
little sense or rapidly tails off without
clear conclusion.
Disengagement from the social world and
reduced emotional arousal or ability to
respond to social stimuli.
Psychosis can be triggered by drug misuse or
can be associated with life changes, such as
childbirth. Post-partum psychosis is a medical
emergency that occurs within days after the
birth of a child and involves significantly
disordered ideas about the birth (Berrisford
et al 2015). Mothers affected by post-partum
psychosis report hallucinations, delusions
and rapidly shifting attitudes, including ideas
about harming or killing their infants. In
Sweden, Engqvist and Nilsson (2013) reported
the despair and horror felt by mothers as they
contemplated harming their infants. Although
the majority of women make good recoveries
from such psychoses, urgent treatment
with antipsychotic medication is necessary
to rebalance neurotransmitter (dopamine)
concentrations in the brain.
Patients and relatives confronted with
hallucinations linked to a new diagnosis of
schizophrenia are especially interested in
understanding how the condition arises.
Explanations of illness are difficult to share
with authority as debates about schizophrenia
continue, so it is necessary to add caveats about
what is known. Howe and Murray (2014)
offered one model of the process. They explained
that an individual might be predisposed to
schizophrenia through genetic, intrauterine
developmental, neurochemical and social
4 Imagine that
you are having a
factors that combine and result in increased
conversation with an
incidence of the condition in adolescence and
adolescent who has
early adulthood. The authors noted a high
been taking legal
incidence of schizophrenia in some families
highs. He tells you
(genetic predisposition), a history of intrauterine
about the trips that he
infections or other adverse events affecting
has experienced while
embryo development (developmental risks) and
taking these drugs,
neurological problems (high dopamine levels and
some good and some
a propensity for the individual to respond quickly
bad. List the risks
to psychological stressors).
of continuing to use
Schizophrenia develops when the young
these drugs?
individual is exposed to a significant volume
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CPD mental health
or variety of social stressors that, along with
the excess of dopamine in the brain, trigger
a crisis. Schizophrenia frequently presents
after a major psychosocial event such as a
divorce or redundancy from work. Migrants,
those treated more marginally in society, and
those leading uncertain or precarious social
lives are exposed to increased levels of stress
and schizophrenia has been noted as more
prevalent in these communities. Palmier-Claus
et al (2013) described this process as stress
sensitisation, emphasising that incremental
negative reactions from others can markedly
increase the chances of a psychosis developing.
If the individual believes strongly that they
should have control of their circumstances,
and their dignity relies on that, repeated social
insults increasingly undermine the individuals
thought processes. As well as the presence of
predisposing factors, the at-risk individual
encounters exceptional social demands that
FIGURE 1
Schizophrenia development and hallucination type
Predisposing factors to schizophrenia (nature)
Genetic predisposition.
History of intrauterine problems, such as infection or hypoxia
(developmental).
Neurological predisposition (dopamine dysfunction at
the synapse).
Social stress triggers (nurture)
Large discrepancies between expected performance (that
which the patient imagines others expect of them) and ability
to perform as expected (feeling unequal to social demands).
Sociopsychological crisis.
Schizophrenia
Predisposition to a form of hallucinations or delusions
Significant doubts about reasoning and coping ability
combined with social expectations and low self-esteem result
in persecutory hallucinations.
The individual feels detached emotionally from others and
hallucinations seem to reinforce this.
Delusions then develop to explain why the individual is
different and why others (real or imagined) behave towards
them as they do.
(Van Oosterhout et al 2013, Howe and Murray 2014)
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place a strain on their reasoning abilities.
Nature and nurture therefore combine to
produce schizophrenia.
However, Howe and Murrays (2014)
model does not specifically account for the
hallucinations that patients with schizophrenia
experience and clinical psychologists have
begun to explore why threatening hallucinations
are so common. Van Oosterhout et al
(2013) studied the beliefs of 77 patients with
schizophrenia who experienced severe auditory
verbal hallucinations. The authors reported
that hostile voices were associated in patients
minds with a lack of belief that they could
control their own experiences; patients had
lost confidence that they were in control of
their own thought processes. There was a
further association between a feeling that they
could not reason coherently and increased
levels of depression and anxiety. Threatening
hallucinations appear to reflect the patients
limited confidence in their social reasoning
and relate to low levels of self-esteem. An
inability to reason as others do evokes voices
that chastise, criticise and censor the individual.
The experience of hearing persecutory voices
reinforces perceptions of low self-worth and
lock the patient into a cycle of critical auditory
hallucinations. In Figure 1, the developing ideas
associated with predisposition to schizophrenia
are linked to the likelihood of particular
hallucinations occurring.
Finding ways to help patients
Hallucinations might not require treatment
if they are the result of normal events, such as
sleep deprivation. Hallucinations can resolve
without treatment when underlying causes
are removed. The patient might require an
explanation of why such experiences have
occurred. However, when schizophrenia has
been diagnosed, there are different ways to
assist the patient and these are influenced by
different premises regarding the origin and
nature of the mental illness. Antipsychotic
medications can be used to manage the
underlying neurological disorder (excess
dopamine production in the brain) and talking
therapies can be used to help manage the
experience of hallucinations and delusions. The
Royal College of Psychiatrists (2014) guidance
pamphlet for patients on antipsychotics
summarises the first and second generation
drugs used and notes that talking therapies,
such as cognitive behavioural therapy (CBT),
are beneficial as well.
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 Schizophrenia is both neurological and
experiential. Antipsychotic medications, such
as chlorpromazine, and talking therapies are
complementary and augment each others
effects, although the relative merits of each
are sometimes contested. Where medication
improves the patients ability to reason, talking
therapies and support groups can help to
sustain patients when they confront residual
hallucinations. Talking therapies might be
especially important in sustaining treatment
concordance if patients experience side effects
associated with their medication.
In a randomised controlled trial of CBT
for patients who were diagnosed with
schizophrenia spectrum disorder, Morrison
et al (2014) made optimistic claims regarding
the benefits of talking therapy versus
conventional antipsychotic medication,
claiming that talking therapy significantly
reduced the symptoms of schizophrenia.
However, procedural flaws in the research,
including failure to note a high drop-out rate
in the study, significantly limited what can
be claimed from these results. In practice,
most patients continue to take antipsychotic
medication and supplement drug treatment
with talking therapies and social support
strategies to help them cope with the
experience of managing a long-term illness.
Questions are sometimes raised by nurses
about whether hallucinations should be
discussed with patients. For example, should
auditory hallucinations be treated merely as
the sequelae of neuropathology and not be
discussed? Conversely, does a discussion of
hallucinations enable the patient to regain
a degree of independence? Talking insensitively
with the patient about their voices can
reinforce delusions. Hayward and May
(2007) distinguished between hallucinations
and delusions, and argued that delusions can
be better countered in a carefully arranged
and supportive group environment in which
patients are encouraged to address their own
voices. Patients worked in groups and were
invited in turn to sit in the centre of the circle
and rehearse aloud what the voices they heard
were saying to them. Establishing trust in
the group was crucical before patients could
safely share such experiences. After recounting
verbatim what the voices were saying, the
patients were encouraged to return to the
group circle and to explore with their peers
what the voices signified and why they might
present as they did. Patients were encouraged to
interrogate their own delusions.
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Woods (2013) described similar
experience-interrogating approaches used
by the Hearing Voices Network. In this
approach, individuals are encouraged to talk
to other voice hearers, to seek explanations
of why voices emerge, and to identify ways
of representing and mastering voices that
intrude on their lives. Patients are believed to
work through three emotional stages in the
management of auditory hallucinations:
Being startled or frightened the initial
encounter with hallucinations produces
confusion, fear, turmoil and a sense
of helplessness.
Becoming organised after the initial
confusion, the patient should search for
a measure of understanding and acceptance,
especially if hallucinations persist in the
long term. The hallucinations should be
represented to oneself and others in some way.
Stabilising the situation any hallucinations
that cannot be resolved through treatment
of underlying conditions should be
accommodated as part of life. Psychological
work can minimise the disruption to
activities of living.
Complete time out activity 5
Nurses are increasingly recognising the need
to discuss hallucinations with patients and
to actively enquire about them (Trygstad
et al 2015). It is important that patients are
interviewed in a consistent way about their
experiences and the nature of hallucinations 5 Examine the
encountered. To do this, Trygstad et al explanations of
(2015) prepared a question guide. The hallucinations on the
guide pays particular attention to whether Hearing Voices Network
hallucinations prompt self-harm or harm to (2016) website: www.
others since nurses should undertake a risk hearing-voices.org/
assessment of patients and refer promptly to voices-visions. Read the
mental health specialists where appropriate. reactions from voice
Patients with mental health problems might hearers who have used
present after injury, for surgery or for physical this website.
complaints, so a holistic assessment of patient H ow are individuals
circumstances and needs is required. using this site to
Buccheri et al (2013) noted a number of make sense of
patient responses that might be used to assist their experiences?
patients to manage auditory hallucinations H ow helpful does
when they present. They identified that this sharing of
voices were more intrusive when the patient experiences seem?
was silent and when the individual dwelled Remember as you study
on their thoughts. One solution is therefore this resource that a
to distract oneself from the voices. Talking variety of users access
to others and using television or music to the service, some with
focus attention elsewhere can be used to no underlying diagnosis
limit the intrusive nature of voices. Buccheri and others who might be
etal (2013) also noted that humming was an dealing with psychosis.
january
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30 without 2016 55
no 21 ::permission.
CPD mental health
effective distraction, and one that has worked
in clinical settings, but it is difficult to use
in social environments because patients fear
other peoples reactions.
Four first-encounter precepts
Because nurses may encounter patients
reporting hallucinations in different
circumstances and without necessarily the
benefit of mental health training, it is important
to work with precepts that can guide first
responses. Patients might experience a number
of different illnesses and until these are assessed
and diagnosed, the nurse must work with
presented symptoms. There is a need to assess
risk and to reassure the patient that they have
the nurses respect.
Precept 1: treat hallucinations as a matter
worthy of serious professional attention
Nurses are engaged with the patients
experiences, so it is rational to attend to
reports of that which cannot be seen or heard,
but which nevertheless exercises the patients
emotions. Hallucinations are often a symptom
of an underlying healthcare problem, such
as a neurological, mental health or drug and
alcohol related problem, and they might
represent risk. In its guidelines for psychosis
and schizophrenia prevention and management
(NICE 2014) and guidelines for psychosis and
schizophrenia in children and young people
(NICE 2013), the importance of prompt
referral for specialist mental health assessment
is emphasised. This is only possible if nurses
attend carefully to what patients report (NICE
2014) and do not dismiss their concerns. They
should pay particular attention to any delusions
the patient shares, especially if they refer to
prompts to harm oneself or others.
Precept 2: listen to the patients emotional
response to hallucinations
Alarm, fear and confusion are often felt
by patients when they first experience a
hallucination. They secure emotional support
from others who recognise that whatever the
basis of their perceptions, it is accepted that
this seems real and bewildering. It is possible
to discuss perceptions and beliefs without
necessarily condoning them as real-life
phenomena. Hallucinations do not invariably
mean that the patient is experiencing mental
illness. There are a number of causes of
hallucinations and some can resolve without
intervention. Those that persist, for example
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those associated with schizophrenia, can be
managed more successfully if the patients
concerns are acknowledged and respected from
the outset. An agitated and distressed patient
quickly senses whether the nurse registers their
concerns by the way that the nurse speaks and
the time they give to the patient. Inviting the
patient to express their concerns, to detail their
experience and how it has disrupted their life
indicates that the nurse is concerned for the
wellbeing of the patient.
Precept 3: make time to take a thorough
history of the patient experience, record it
clearly and make referrals as appropriate
Nurses working with patients who have
physical injuries and illnesses are less
expert than those working in mental
healthcare settings at assessing mental
health problems and should not extend their
assessments beyond their level of competence.
Nevertheless, the principles of good history
taking remain: when did the experience occur,
what preceded it, what form did it take and
what does the patient believe was happening?
Has there been a history of neurological
illness, drug or alcohol abuse, or has the
patient recently given birth? Did the reported
hallucination seem to be associated with a
delusion and did the hallucination command
self-harm or harm towards others? A clearly
recorded history of experiences can assist
mental health professionals in making a more
accurate diagnosis.
Precept 4: alert patients and their families
and carers to sources of information that can
help them make sense of their experiences
While the origins of hallucinations and
delusions are investigated, patients and
their relatives still feel the need to make sense
of a disturbing experience. A significant part
of coping with hallucinations is representing
them in some way to oneself. Although the
underlying cause of hallucinations is likely
to be revised as tests are completed and a
diagnosis is arrived at, the process of sense
making will have tentatively begun and
some relief secured from the first feelings
of panic. It is important to remember,
however, that additional sources of
information are only valuable if the patient
is not in crisis and can reflect adequately
on their experiences. It is important that
nurses consider whether the patient is
reasoning clearly before recommending that
they access resources.
other uses without permission.
Conclusion
This article has discussed hallucinations
and delusions as important phenomena.
Although hallucinations are more commonly
discussed in the mental health setting, they
do occur in general care and nurses should
be prepared to deal with them. An
understanding of what hallucinations are,
how they differ from delusions and how the
two might relate to one another, alert the
nurse to the importance of taking a clear
history and making referrals to mental
health specialists when psychoses are
suspected. However, it is emphasised
that many conditions that can be associated
with hallucinations are not necessarily
associated with mental illness. Where
hallucinations persist, there is a need to
manage them.
Much remains unclear about the
underlying mechanisms of hallucinations,
but some tentative suggestions have been
offered. What remains clear, however, is that
hallucinations are disturbing for patients and
that the nurse should help the patient and their 6 Now that you have
relatives to start dealing with this as part of completed the article,
the support provided. If patients are to cope you might like to write
with hallucinations in the long term, it is a reflective account as
important that they are assisted to manage the part of your revalidation.
intrusion well so that they can optimise their Guidelines to help you
activities of daily living NS are on page 62.
Complete time out activity 6

References
Alzheimers Society (2012) Sight,
Perception and Hallucinations in
Dementia. www.alzheimers.org.
uk/site/scripts/download_info.
php?fileID=1837 (Last accessed:
November 19 2015.)
American Psychiatric Association
(2013) Diagnostic and Statistical
Manual of Mental Disorders.
Fifth edition. American Psychiatric
Association Publishing,
New York NY.
Bauer SM, Schanda H, Karakula H
et al (2011) Culture and the
prevalence of hallucinations in
schizophrenia. Comprehensive
Psychiatry. 52, 3, 319-325.
Beavon V, Read J, Cartwright C
(2011) The prevalence of
voice-hearers in the general
population: a literature review.
Journal of Mental Health.
20, 3, 281-292.
Berrisford G, Lambert A, Heron J
(2015) Understanding postpartum
psychosis. Community Practitioner.
88, 5, 22-23.
Bivin JB, Gandhi S, John JP
(2014) Patterns of auditory
verbal hallucination among
patients diagnosed with chronic
schizophrenia. International
Journal of Nursing Education. 6,
1, 117-121.
Brewer TL, Collins M (2014)
A review of clinical manifestations
in adolescent and young adults
after use of synthetic cannabinoids.
Journal for Specialists in Paediatric
Nursing. 19, 2, 119-126.
Buccheri R, Trygstad L, Buffum M,
Birmingham P, Dowling G (2013)
Self-management of unpleasant
auditory hallucinations: a tested
practice model. Journal of
Psychosocial Nursing and Mental
Health Services. 51, 11, 26-34.
Choong C, Hunter MD, Woodruff PW
(2007) Auditory hallucinations
in those populations that do not
suffer from schizophrenia. Current
Psychiatry Reports. 9, 3, 206-212.
Cockburn P, Cockburn H (2011)
Henrys Demons: Living with
Schizophrenia, A Father and Sons
Story. Scribner, New York NY.
Cuesta MJ, Ugarte MD, Goicoa T,
Eraso S, Peralta V (2007) A
taxometric analysis of schizophrenia
symptoms. Psychiatry Research.
150, 3, 245-253.
Devery K, Rawlings D, Tieman J,
Damarell R (2015) Deathbed
phenomena reported by patients in
palliative care: clinical opportunities
and responses. International Journal
of Palliative Nursing. 21, 3, 117-125.
Elliot SR (2014) ICU delirium:
a survey into nursing and medical
staff knowledge of current practices
and perceived barriers towards ICU
delirium in the intensive care unit.
Intensive and Critical Care Nursing.
30, 6, 333-338.
Engqvist I, Nilsson K (2013)
Experiences of the first days of
postpartum psychosis: an interview
study with women and next of kin
in Sweden. Issues in Mental Health
Nursing. 34, 2, 82-89.
Fountain A, Kellehear A (2012) On
prevalence disparities in recent
empirical studies of deathbed
visions. Journal of Palliative Care.
28, 2, 113-115.
Hallak JE, Maia-de-Oliveira JP,
Abrao J et al (2013) Rapid
improvement of acute schizophrenia
symptoms after intravenous sodium
nitroprusside: a randomized,
double-blind, placebo-controlled
trial. JAMA Psychiatry.
70, 7, 668-676.
Hayward M, May R (2007) Daring
to talk back. Mental Health Practice.
10, 9, 12-15.
Hearing Voices Network (2016)
Basic Information About Voices
and Visions. www.hearing-voices.
org/voices-visions (Last accessed:
November 19 2015.)
Howe OD, Murray RM (2014)
Schizophrenia: an integrated
sociodevelopmental-cognitive model.
The Lancet. 383, 9929, 1677-1687.
Jordaan GP, Nel DG, Hewlett RH,
Emsley R (2009) Alcohol-induced
psychotic disorder: a comparative
study on the clinical characteristics
of patients with alcohol dependence
and schizophrenia. Journal of
Studies on Alcohol and Drugs.
70, 6, 870-876.
Kahn RS, Keefe RS (2013)
Schizophrenia is a cognitive illness:
time for a change in focus. JAMA
Psychiatry. 70, 10, 1107-1112.
Lieberman JA, Dixon LB, Goldman HH
(2013) Early detection and
intervention in schizophrenia:
a new therapeutic model. JAMA.
310, 7, 689-690.
Mlodinow L (2011) What is the
connection between mind and
brain? In Chopra D, Mlodinow L
(Eds) War of Worldviews:
Science vs Spirituality. Rider,
London, 174-181.
Morrison AP, Turkington D, Pyle M
et al (2014) Cognitive therapy for
people with schizophrenia spectrum
disorders not taking antipsychotic
drugs: a single-blind randomised
controlled trial. The Lancet. 383,
9926, 1395-1403.
National Institute for Health and
Care Excellence (2013) Psychosis
and Schizophrenia in Children and
Young People: Recognition and
Management. Clinical guideline No.
155. NICE, London.
National Institute for Health and
Care Excellence (2014) Psychosis
and Schizophrenia in Adults:
Prevention and Management.
Clinical guideline No. 178.
NICE, London.
NHS Choices (2014) Psychosis.
www.nhs.uk/conditions/Psychosis/
Pages/Introduction.aspx (Last
accessed: November 19 2015.)
Palmier-Claus JE, Dunn G, Taylor H,
Morrison AP, Lewis SW (2013)
Cognitive-self consciousness
and metacognitive beliefs: stress
sensitization in individuals at
ultra-high risk of developing
psychoses. British Journal of Clinical
Psychology. 52, 1, 26-41.

NURSING STANDARD
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from RCNi.com by ${individualUser.displayName} on Jul 04, 2016. For personal use 20other
only. No :: voluses
30 without 2016 57
no 21 ::permission.
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CPD mental health

Parkinsons UK (2013) Hallucinations
and Delusions in Parkinsons. tinyurl.
com/nwpeyoe (Last accessed:
November 19 2015.)
Rainier NC (2014) Reducing physical
restraint use in alcohol withdrawal
patients: a literature review.
Dimensions of Critical Care Nursing.
33, 4, 201-206.
Roberts B, Chaboyer W (2004)
Patients dreams and unreal
experiences following intensive care
unit admission. Nursing in Critical
Care. 9, 4, 173-180.
Royal College of Psychiatrists (2014)
Antipsychotics. www.rcpsych.ac.uk/
healthadvice/treatmentswellbeing/
antipsychoticmedication.aspx (Last
accessed: November 19 2015.)
Royal National Institute for the
Blind (2015) Charles Bonnet
Syndrome. tinyurl.com/kjcuafw
(Last accessed: November 19 2015.)
Schneider MA, Schneider MD (2013)
Strange sightings: is it Charles
Bonnet syndrome? Nursing.
43, 7, 52-55.
Sharma V (2014) Mental health
morbidity in older adults: psychosis.
Journal of Psychiatric Nursing.
3, 2, 41-76.
Somerville JG (2014) Risk for
compromised human dignity:
the nursing challenge. Nursing
Management. 45, 5, 39-41.
Subramanian P, Burhan A,
Pallaveshi L, Rudnick A (2013)
The experience of patients
with schizophrenia treated
with repetitive transcranial
magnetic stimulation for
auditory hallucinations.
Case Reports in Psychiatry.
doi:10.1155/2013/183582.
Teeple RC, Caplan JP, Stern TA
(2009) Visual hallucinations:
differential diagnosis and treatment.
Primary Care Companion to the
Journal of Clinical Psychiatry.
11, 1, 26-32.
Trygstad LN, Buccheri RK,
Buffum MD, Ju D, Downing GA
(2015) Auditory hallucinations
interview guide: promoting recovery
with an interactive assessment
tool. Journal of Psychosocial
Nursing and Mental Health Services.
53, 1, 20-28.
Van der Linde RM, Dening T,
Matthews FE, Brayne C (2014)
Grouping of behavioural and
psychological symptoms of
dementia. International Journal of
Geriatric Psychiatry. 29, 6, 562-568.
Van Oosterhout B, Krabbendam L,
Smeets G, Van der Gaag M (2013)
Metacognitive beliefs, beliefs
about voices and affective
symptoms in patients with
severe auditory verbal
hallucinations. British Journal
of Clinical Psychology.
52, 3, 235-248.
Verdoux H, Van Os J (2002)
Psychotic symptoms in non-clinical
populations and the continuum of
psychosis. Schizophrenia Research.
54, 1-2, 59-65.
Waters F, Stephane M (2015)
The Assessment of Psychosis:
A Reference Book and Rating
Scales for Research and
Practice. Routledge, New York NY.
Woods A (2013) The voice-hearer.
Journal of Mental Health.
22, 3, 263-270.

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CPD assessment

Hallucinations
TEST YOUR KNOWLEDGE BY COMPLETING SELF-ASSESSMENT QUESTIONNAIRE 827

1. Which of the following statements 7. Which factor does not predispose How to use this assessment
is incorrect? to the development of schizophrenia?
This self-assessment questionnaire (SAQ)
a) Hallucinations are sensations a) Genetic predisposition
will help you to test your knowledge. Each
experienced in the absence of b) Adverse events during embryonic week you will find ten multiple-choice
external stimuli development questions that are broadly linked to the
b) Delusions are false and fixed  ow dopamine levels in the
c) L CPD article. Note: there is only one
beliefs that do not relate to brain correct answer for each question.
reality d) A major psychosocial event such
c) Delusions and hallucinations as divorce or redundancy 
You could test your subject knowledge
only occur in mental illness by attempting the questions before
reading the article, and then go back
d) Delusions and hallucinations 8. Which of these statements is false?
over them to see if you would answer
often occur at the same time a) A ll hallucinations are threatening
any differently.
and frightening for the person
2. What proportion of people with b) Hallucinations are common in 
You might like to read the article to
schizophrenia are estimated to patients who are dying update yourself before attempting
experience auditory hallucinations?  allucinations may be temporary
c) H the questions.
a) One quarter and resolve spontaneously When you have completed your
b) One half d) Hallucinations become less selfassessment, add it to your professional
c) Three quarters frequent when the person is portfolio. You can record the amount of
d) All distracted time it has taken. Space has been provided
for comments.
3. Hallucinations may be experienced: 9. Which of the following is not a
a) After a bereavement symptom of psychosis? You might like to consider writing a
b) Following loss of sight a) Disordered ideation reflective account, see page 62.
c) I n patients who are sedated and b) Small shifts in mood
intubated in intensive care c) Disengagement from social
d) All of the above interaction Report back
d) Delusions This activity has taken me _____ hours to
4. Which of the following is not an complete.
underlying cause of hallucinations? 10. Post-partum psychosis: Other comments:
a) Diabetes a) Is not a medical emergency
b) Drug or alcohol misuse b) Should be treated urgently with
c) Parkinsons disease antidepressants
d) Dementia c) Should be treated urgently with
antipsychotics
5. Psychosis is a result of abnormal d) A lways manifests before the birth
levels of which neurotransmitter of an infant Now that I have read this article and
in the brain? completed this assessment, I think
a) Glutamate This self-assessment questionnaire my knowledge is:
b) Dopamine was compiled by Rebecca Akkermans Excellent
c) Acetylcholine Good
d) Gamma-aminobutyric acid The answers to this questionnaire will Satisfactory
be published on February 3 Unsatisfactory
6. What is Charles Bonnet syndrome Poor
caused by? The answers to SAQ 825 on diabetes, As a result of this I intend to:
a) Damage to the visual cortex which appeared in the January 6
b) Damage to the auditory issue, are:
cortex 1. d 2. a 3. c 4. b 5. d
c) L oss of vision, for example as a 6. c 7. a 8. b 9. d 10. c
result of macular degeneration
d) None of the above

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