Currently Viewing:
Psych Congress 2015

Are Hallucinations Real or Fake? An Expert Teaches How to Tell the Difference

Mary K. Caffrey
Becoming familiar with the subtle signs that a hallucination is fake can allow psychiatrists to keep patients out of the hospital when they have no business being there.
From getting a warm bed and a hot meal, to avoiding the death penalty for a gruesome crime, there are powerful incentives for people to pretend to they are hearing voices—and, more precisely, that voices are telling them to do things.

So how can psychiatrists—or an emergency room nurse—distinguish genuine hallucinations from those manufactured for financial or personal gain? It’s not easy, but there are telltale signs, as well as revised thinking gleaned from brand-new research, said Phillip J. Resnick, MD, a professor of psychiatry at Case Western Reserve University. Resnick’s review Saturday in “The Detection of Malingered Mental Illness” was one of the more fascinating sessions at the 28th US Psychiatric and Mental Health Congress in San Diego, California.

While the idea of fake hallucinations may be most associated with criminals trying to avoid prosecution, there are thousands of attempts each year by inmates and the homeless to get “three hots and a cot” in a state mental institution, since this represents an upgrade from current surroundings. Prisoners may also be laying the groundwork for collecting disability benefits upon release, he said.

The combination of federal parity laws and more states moving to Medicaid managed care makes it imperative that mental health professionals and emergency room staff be able to separate the malingerers from those truly in need, given limited resources. Resnick noted that some who fake hallucinations may have a serious mental health diagnosis such as schizophrenia, even if they are inventing the “voices” in question. Matching the story in the hallucination with the medical record may help tease out what is true in these cases.

Malingering, Resnick said, involves inventing or exaggerating symptoms. “Every malingerer is an actor portraying an illness,” and for healthcare professionals, knowing more about that illness is key. “The more you know about the illness, the more you can ask questions that the malingerer will not know.”

When cornered, the malingerer’s story will fall apart, or it may become so overblown that the ruse becomes apparent. Overdoing it is the malingerer’s biggest mistake, he said. “We know people have grandiose ideas that they are Jesus Christ, but they don’t come in costume to the doctor.”

Psychotic vs. Nonpsychotic. Not every “vision” or “voice” is a sign of psychosis, Resnick said. “About 25% of widows report they have seen their dead husband,” he said. Understanding cultural context is key, because patients from more religious countries may report voices from God that do not represent psychosis, while auditory hallucinations from US patients tend to be more harsh and less focused on religion.

New research from Australia contradicted some prior assumptions: visual freestanding hallucinations were thought to be rare, but that is not the case.

Separating Real from Fake. What should a psychiatrist look for? “Genuine hallucinations are most often associated with delusions. Someone who has hallucinations in the absence of delusions is less typical and you would have a higher index of suspicion,” he said.

Copyright AJMC 2006-2020 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up