Abstract
Hallucinations constitute one of the 5 symptom domains of psychotic disorders in DSM-5, suggesting diagnostic significance for that group of disorders. Although specific featural properties of hallucinations (negative voices, talking in the third person, and location in external space) are no longer highlighted in DSM, there is likely a residual assumption that hallucinations in schizophrenia can be identified based on these candidate features. We investigated whether certain featural properties of hallucinations are specifically indicative of schizophrenia by conducting a systematic review of studies showing direct comparisons of the featural and clinical characteristics of (auditory and visual) hallucinations among 2 or more population groups (one of which included schizophrenia). A total of 43 articles were reviewed, which included hallucinations in 4 major groups (nonclinical groups, drug- and alcohol-related conditions, medical and neurological conditions, and psychiatric disorders). The results showed that no single hallucination feature or characteristic uniquely indicated a diagnosis of schizophrenia, with the sole exception of an age of onset in late adolescence. Among the 21 features of hallucinations in schizophrenia considered here, 95% were shared with other psychiatric disorders, 85% with medical/neurological conditions, 66% with drugs and alcohol conditions, and 52% with the nonclinical groups. Additional differences rendered the nonclinical groups somewhat distinctive from clinical disorders. Overall, when considering hallucinations, it is inadvisable to give weight to the presence of any featural properties alone in making a schizophrenia diagnosis. It is more important to focus instead on the co-occurrence of other symptoms and the value of hallucinations as an indicator of vulnerability.
Highlights
The personal, cultural, and clinical significances of hallucinations have changed in the 200 years since they were defined by Esquirol as “the intimate conviction of perceiving a sensation for which there is no external object.”[1,2] There is a growing recognition that hallucinatory experiences attend a wide variety of psychiatric diagnoses and can be part of everyday experience for people who do not meet criteria for mental illness
Not diagnostic of schizophrenia when occurring in isolation, the presence of persistent auditory hallucinations is sufficient for a diagnosis of Other Specified Schizophrenia Spectrum and Other Psychotic Disorder, if it is combined with clinically significant distress or functional impairment
It is increasingly recognized that hallucinations occur with significant frequency in other psychiatric and medical conditions and that they are especially predictive of multimorbid psychopathology.[6,7]
Summary
The personal, cultural, and clinical significances of hallucinations have changed in the 200 years since they were defined by Esquirol as “the intimate conviction of perceiving a sensation for which there is no external object.”[1,2] There is a growing recognition that hallucinatory experiences attend a wide variety of psychiatric diagnoses and can be part of everyday experience for people who do not meet criteria for mental illness. Since the earliest clinical texts, auditory hallucinations have been closely linked to schizophrenia.[3,4] Hallucinations constitute one of the 5 domains of abnormality of schizophrenia spectrum and other psychotic disorders in DSM-5. Not diagnostic of schizophrenia when occurring in isolation, the presence of persistent auditory hallucinations is sufficient for a diagnosis of Other Specified Schizophrenia Spectrum and Other Psychotic Disorder, if it is combined with clinically significant distress or functional impairment Candidate distinguishing features that have become important diagnostically include negative and derogatory auditory hallucinations; command hallucinations; voices heard conversing about the individual in the third person; and location in external space.[4,5,8]
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