Visual hallucinations are sensory experiences of seeing things that are not physically present.
Studying visual hallucinations is crucial because they can significantly impact a person’s quality of life, functioning, and mental health.
Understanding their nature and mechanisms can lead to better diagnostic tools, more effective treatments, and improved support for individuals experiencing these often distressing phenomena.
Aynsworth, C., Waite, F., Sargeant, S., Humpston, C., & Dudley, R. (2024). Visual hallucinations in psychosis: What do people actually see?. Psychology and Psychotherapy: Theory, Research and Practice. https://doi.org/10.1111/papt.12553
Key Points
- The primary findings of this study on visual hallucinations in psychosis include:
- People with psychosis primarily see visions of people or human-like beings.
- Visions often have a compelling sense of reality, sharing the same perceptual qualities as real people or objects.
- The content of visions is often linked to past traumatic experiences.
- Visions are typically multimodal, involving different sensory modalities like touch and speech.
- The coherence and quality of visions contribute to their distressing nature and impact on people’s lives.
- Factors like content (what is seen), coherence (how real it behaves), and quality (how real it looks) significantly affect the experience and distress associated with visual hallucinations in psychosis.
- This research has certain limitations such as a predominantly White British sample and focus on the most distressing visions.
- Understanding the phenomenology of visual hallucinations is crucial for developing effective treatments and supporting individuals with psychosis.
Rationale
Visual hallucinations are common in psychosis, affecting approximately one in three people with first-episode psychosis (Allen et al., 2023).
These experiences are associated with significant clinical consequences, including more frequent and prolonged hospital admissions, greater likelihood of suicide, impaired functioning, and greater symptom severity (Baethge et al., 2005; Mueser et al., 1990; Oorschot et al., 2012; Kreis et al., 2024).
Despite their prevalence and impact, there is currently a lack of effective treatment for visual hallucinations in psychosis (Collerton et al., 2005; Thomson et al., 2017; Wilson et al., 2015).
To develop more helpful psychological therapies, a detailed understanding of the unique features and mechanisms contributing to visual hallucinations is necessary.
While previous research has explored the phenomenology of visual hallucinations using quantitative measures, there is still a crucial lack of detailed phenomenological description and understanding.
This study aims to address this gap by gathering first-hand accounts of the experience of visual hallucinations in people with psychosis.
Method
The study employed a qualitative design using semi-structured interviews.
A Lived Experience Advisory Panel (LEAP) helped design the study and contributed to the interpretation of findings.
The research was approved by the NHS Health Research Authority Newcastle and North Tyneside 1 Research Ethics Committee.
A critical realist ontological approach and contextualist epistemology underpinned the study.
Reflexive thematic analysis, following Braun and Clarke’s six-phase approach, was used to analyze the data.
The lead researcher (CA) conducted bracketing interviews, kept a reflexive journal, and regularly discussed coding and themes with supervisors and a peer researcher with lived experience to ensure reflexivity and quality.
Sample
Twelve participants (8 male, 4 female; mean age 38.1 years, SD = 10.9, range 22-58) were recruited from NHS psychosis services in the North East of England.
Inclusion criteria were: current experiences of visual hallucinations, psychosis spectrum diagnosis, receiving care within an NHS mental health team, aged 16 years or above, and willing and able to provide informed consent.
Exclusion criteria included visual hallucinations only under the influence of drugs/alcohol or on the borders of sleep, fleeting or rare visual hallucinations, significant brain injury or neurological condition, and moderate to severe learning disability.
Results
Three main themes were generated:
1. Content: People see people
Participants primarily reported seeing visions of humans or human-like beings.
Subtheme: Links with the past
Quote: “I see the older version of [past abuser]. The one I see more clearly is the older [version of abuser], but the younger [version of the abuser] is the one that strangles me.” (Lily)
Subtheme: Uncanny Valley
Quote: “I can tell it’s a man. He’s quite big. You can see everything…But no face, no hair, just like bald…No features whatsoever…It’s as if I’m seeing three quarters of it and the rest hasn’t loaded.” (Mick)
2. Coherence: Visions of people who behave like people
Visions often involved multiple sensory modalities, adding to their compelling nature.
Subtheme: Coherency mirrors mood
Quote: “Well, sometimes she talks to us when she’s there, when I can see her…when she talks it’s very negative. A lot of the time it’s when I’m really, really low and I’m feeling really low about meself.” (Sarah)
3. Quality: They look too real
Visions had a compelling sense of reality, sharing the same level of perceptual detail as real people or objects.
Quote: “These visions have always been very real to me, they’re as real as you to me sitting [there], I could be touching you and it would feel like I’m touching a human, so they’re not something like smoke when you put your hand through it, it disappears. They’re very physical and they’re very real.” (Emily)
Insight and Depth
This study provides a comprehensive framework for understanding the phenomenology of visual hallucinations in psychosis, focusing on content, coherence, and quality.
The findings challenge the traditional view of visual hallucinations as fleeting, unimodal experiences lacking perceptual clarity.
Instead, they reveal that these experiences are complex, vivid, and absorbing, sharing the same perceptual qualities as real-world stimuli.
The study’s insights into the links between visual hallucinations and past traumatic experiences, as well as the impact of mood on the coherence of visions, offer valuable directions for future research and therapeutic interventions.
Implications
The findings have significant implications for both clinical practice and research.
The framework of content, coherence, and quality can guide the development of more comprehensive assessment tools and inform clinical interviews.
This deeper understanding of visual hallucinations can support the delivery of core therapeutic principles, such as normalizing and empathy, to reduce internalized stigma and enhance therapeutic alliance.
The study also highlights the potential for developing targeted techniques based on the “Uncanny Valley” observation, which could help individuals question the reality of their visions and develop more helpful coping strategies.
Strengths
The study had many methodological strengths including:
- Use of first-hand accounts to gather detailed descriptions of visual hallucinations
- Involvement of a Lived Experience Advisory Panel in study design and interpretation
- Rigorous qualitative methodology, including reflexive thematic analysis
- Inclusion of participants from various mental health services
- In-depth exploration of the phenomenology of visual hallucinations
Limitations
The study’s limitations include:
- Predominantly White British sample, which may not capture cultural variations in the experience of visual hallucinations
- Focus on the most distressing visions, potentially overlooking less problematic experiences
- Limited generalizability to non-clinical populations or individuals with visual hallucinations in other conditions
- Potential influence of researcher subjectivity on data interpretation, despite efforts to maintain reflexivity
Conclusion
This study provides a crucial step towards a more comprehensive understanding of visual hallucinations in psychosis.
By exploring the content, coherence, and quality of these experiences, it offers valuable insights for both researchers and clinicians.
The findings challenge existing notions about the nature of visual hallucinations and highlight the complex, vivid, and absorbing nature of these experiences.
Future research should focus on expanding this understanding to diverse populations and exploring how these insights can be translated into more effective therapeutic interventions.
As we continue to unravel the complexities of visual hallucinations, it is essential to approach this sensitive topic with empathy and recognition of its profound impact on individuals’ lives.
References
Primary reference
Aynsworth, C., Waite, F., Sargeant, S., Humpston, C., & Dudley, R. (2024). Visual hallucinations in psychosis: What do people actually see?. Psychology and Psychotherapy: Theory, Research and Practice. https://doi.org/10.1111/papt.12553
Other references
Allen, S., Goodall, T., Jones, C., James, R., & Surtees, A. (2023). What is the prevalence of visual hallucinations in a first-episode psychosis population? A systematic review and meta-analysis of the literature. Schizophrenia Bulletin Open, 4(1), sgad002. https://doi.org/10.1093/schizbullopen/sgad002
Baethge, C., Baldessarini, R. J., Freudenthal, K., Streeruwitz, A., Bauer, M., & Bschor, T. (2005). Hallucinations in bipolar disorder: characteristics and comparison to unipolar depression and schizophrenia. Bipolar disorders, 7(2), 136-145. https://doi.org/10.1111/j.1399-5618.2004.00175.x
Collerton, D., Perry, E., & McKeith, I. (2005). Why people see things that are not there: a novel perception and attention deficit model for recurrent complex visual hallucinations. Behavioral and Brain Sciences, 28(6), 737-757.
Kreis, I., Wold, K. F., Åsbø, G., Simons, C., Flaaten, C. B., Engen, M. J., Lyngstad, S. H., Widing, L. H., Ueland, T., & Melle, I. (2024). The relationship between visual hallucinations, functioning, and suicidality over the course of illness: A 10-year follow-up study in first-episode psychosis. Schizophrenia, 10(1), 30. https://doi.org/10.1038/s41537-024-00450-8
Mueser, K. T., Bellack, A. S., & Brady, E. U. (1990). Hallucinations in schizophrenia. Acta Psychiatrica Scandinavica, 82(1), 26-29.
Oorschot, M., Lataster, T., Thewissen, V., Lardinois, M., van Os, J., Delespaul, P. A. E. G., & Myin-Germeys, I. (2012). Symptomatic remission in psychosis and real-life functioning. The British Journal of Psychiatry, 201(3), 215-220.
Thomson, C., Wilson, R., Collerton, D., Freeston, M., & Dudley, R. (2017). Cognitive behavioural therapy for visual hallucinations: an investigation using a single-case experimental design. The Cognitive Behaviour Therapist, 10, e10.
Wilson, R., Collerton, D., Freeston, M., Christodoulides, T., & Dudley, R. (2016). Is seeing believing? The process of change during cognitive–behavioural therapy for distressing visual hallucinations. Clinical Psychology & Psychotherapy, 23(4), 285-297. https://doi.org/10.1002/cpp.1962
Keep learning
Suggested Socratic questions for a college class to discuss this paper:
- How might the content, coherence, and quality of visual hallucinations interact to influence an individual’s distress and functioning?
- In what ways could cultural factors influence the experience and interpretation of visual hallucinations? How might this study’s findings be different if conducted in a more diverse population?
- How might the link between past traumatic experiences and the content of visual hallucinations inform therapeutic approaches? What ethical considerations should be taken into account when exploring these connections?
- Given the study’s findings on the multimodal nature of visual hallucinations, how might this impact our understanding of the underlying neural mechanisms involved?
- How could the “Uncanny Valley” observation be leveraged in developing coping strategies for individuals experiencing visual hallucinations? What potential benefits and risks might be associated with this approach?
- Considering the study’s limitations, what further research would you propose to address gaps in our understanding of visual hallucinations in psychosis?
- How might the phenomenology of visual hallucinations in psychosis differ from those experienced in other conditions, such as neurodegenerative disorders or eye diseases? How could we design a study to explore these differences?
- What are the potential implications of this research for reducing stigma associated with psychosis and visual hallucinations? How might public understanding of these experiences be improved based on these findings?
