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

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.

In a real hallucination, the patient would be told he is worthless; he may experience unpleasant odors or tastes and may be convinced he is being poisoned. There is a consistency to the experience; in contrast, a fake hallucination seems all over the place, and more unbearably distressing and abusive.

A key red flag comes if the patient puts a condition on the encounter, such as, “If you don’t admit me to the hospital, I’m going to kill myself.” One emergency room nurse told Resnick she has a patient who has made this threat repeatedly; she asked how to document this encounter for liability purposes. Resnick said patients have been known to injure themselves slightly in attempts to authenticate fake hallucinations and pressure healthcare personnel to get what they want.

But some “command” hallucinations are sincere, most often those involving self-harm. “The number one factor that a harmful hallucination will be obeyed is if there’s a related delusion,” Resnick said. A woman told to murder her husband would probably not act unless she also had a delusion that her husband was an “evil wizard,” he said.

When patients can identify the voice, it indicates the hallucination is genuine and they are more likely to act, so this is when psychiatrists must be on guard.

Gender-based insults are common in real hallucinations. Women report being labeled promiscuous, while men hear insults related to homosexuality (the language for each is typically vulgar). Hallucinations of animals are very uncommon, and “little green men” do occur, but usually in alcoholic hallucinations.

How Patients Respond. A patient’s reaction to hallucinations can be an indicator of authenticity. If the patient tries to get rid of the voices on his own, by playing music or humming, or seeking extra medication, this is a sign they are real.

Responses to antipsychotics are also revealing: “At 1 month, people with auditory hallucinations find them less loud and distressing. At 6 months, they’re less frequent, the person feels more control, and they’re more likely to recognize that they are the source.”

But Resnick warned that not all patients experience hallucinations as “bad” events, and psychiatrists must keep this in mind. At times, the voices are benevolent, and for patients who are lonely and have no one to talk to, telling them that the medication will “make the voices go away,” may not be a good strategy. “If you don’t ask whether the voices are malevolent or benevolent, this may be the reason for noncompliance (with medication).”

For patients who want to get rid of voices, “The number 1 strategy is praying.”