Hallucinations and the Mental Health Act

I’ve been reading the late Oliver Sacks’ excellent book Hallucinations. Not surprisingly, in view of the book’s title, it consists of a wide range of accounts of different medical conditions that can produce hallucinations or hallucinatory experiences. As Sacks says: “In the popular imagination hallucinatory voices are almost synonymous with schizophrenia – a great misconception, for most people who do hear voices are not schizophrenic.”

In fact, most of the conditions he writes about do not amount to mental illness at all. One such example is Charles Bonnet Syndrome, where sufferers can experience very vivid hallucinations.

For them, the condition is a result of blindness, and Sacks discusses a range of conditions or situations that produce hallucinations of various types as a result of sensory deprivation of various kinds, ranging from physical states such as blindness to self imposed states of sensory deprivation such as immersion in salt tanks, tanks of warm salt water, where one can lie in a state of suspension and with the entire absence of external stimuli.

It appears that when the conscious brain has nothing to do, it can create often complex and elaborate, but completely unreal, visual and auditory environments.

One of the crucial distinctions between hallucinations arising from physical disease and those experienced by people with psychosis is that the people experiencing these phenomena have complete insight and recognise them not to be real, and tend not have any accompanying delusions.

One of Sacks’ conclusions appears to be that hallucinations can be experienced by anyone, as a normal part of life experience, whether as a result of some physical process, such as migraine or epilepsy, or as an entirely normal part of the functioning of the brain, such as hypnogogic hallucinations (hearing or seeing something when about to fall asleep) or sleep paralysis, which can occur when someone is waking up from sleep, during which time the person can believe themselves to be awake when in fact they are still asleep.

The fact that experiencing hallucinations does not invariably mean that someone is mentally ill is an important factor to consider when assessing people’s mental health, whether under the Mental Health Act, or as a standard mental health assessment.

When I worked in a community mental health team, we conducted standard assessments which included the question “Have you ever heard a voice when there has been no-one around?” Probably around 15% of those I asked answered that they did, but hardly any of them appeared to be psychotic.

One woman told me that every day, as she walked with her child to school, she would hear a voice calling her name at a particular point on the journey. I asked her what she did about it.

“Oh,” she said, “I decided to take a different route to school, and I never heard the voice again.”

I was once asked to assess a woman who was severely disabled by multiple sclerosis. Although living with a partner, he went to work and she was alone for much of the day, and unable to move about or do much for herself. She reported to the GP that her day was spent in the company of film and TV celebrities, who would visit her and entertain her.

After interviewing her, I concluded that her mind was compensating for the loneliness and isolation and general lack of external stimulation, by populating her empty home with people she had seen on TV.

She did not need detention in hospital or antipsychotic medication. She just needed useful daytime occupation, which could be provided through involvement with support workers, day centres and other social activities outside the home.

I have certainly had experiences that could be regarded as hallucinations. On occasion, I have heard a voice just as I was about to fall asleep, which has jerked me awake.

And once I woke up in the middle of the night when a full moon was shining into the room. I could not recognise where I was and sleepily got out of bed to look out of the window. The angles and shadows of the moonlight outside made me think that I was seeing a completely unfamiliar and unknown environment.

At that point my partner woke up and asked me what I was doing. “I don’t know where we are,” I replied.

She got up and also looked out of the window, and for a short time we shared the belief that we had somehow been transported as we slept to a completely different world. Eventually, one of us found a light switch, and the light from the bulb instantly oriented us to the familiar room.

I always try to be open minded when I am listening to patients telling me about their experiences. Sometimes what someone says may seem so unlikely as to be a sign of mental disorder, but which later turns out to be true.

An example is Edna, an lady in her late 80’s who used to live in Charwood in an old semi-detached flint cottage. She complained to her doctor that she kept hearing strange noises in her house and feared that the house was haunted. Concerned that she was experiencing auditory hallucinations, the doctor arranged for an older people’s mental health nurse to visit her.

Edna was insistent that she was indeed hearing strange noises. She knew they were in the house, but could not identify where they were coming from. However, as no untoward sounds were apparent while the nurse was there, the nurse became convinced that the only explanation was that Edna had dementia. He persuaded her to agree to be admitted to hospital for further assessment.

A few days later, the nurse went to her house to collect some personal effects for her. While there, he was startled to hear inexplicable noises emanating from somewhere within the cottage, when he knew there was no-one else in the property.

It eventually transpired that the two cottages both had cellars, although Edna’s cellar was not accessible from her house. The next door neighbour had knocked his own cellar through into the lady’s cellar, and had been converting it into additional accommodation for himself.

Edna had been hearing her neighbour’s d-i-y activities directly beneath her feet.

So when I am making an assessment as to whether or not someone is experiencing mental illness, I do not automatically discount reports of hearing voices or noises, or even seeing things that others don’t see as evidence of disorder. I will make efforts to check for myself to exclude more mundane explanations before getting out the pink papers.