Hallucinations and delusions are most likely to be experienced by those who suffer from

Definitions of Key Terms

Hallucination

A perception that cannot be explained by stimuli in the physical environment, such that a person hears [auditory hallucinations, also called ‘hearing voices’], sees [visual hallucinations], feels [tactile hallucinations, or somatic hallucinations when the sensation occurs within the body], smells [olfactory hallucinations], or tastes [gustatory hallucinations] something that no one else within their environment can detect.

A graduate training approach in psychology that encourages clinicians to utilise, critically evaluate, and produce new research findings [also called the Boulder Model or the research–practitioner model].

Translation from basic scientific research findings to new clinical interventions and practises, with the aim to inform health practice and policy.

Out-patient clinics, which target hallucination-type experiences, the most common of which are auditory [hence the title ‘voices’ clinic].

Clinical practice that integrates the best available research evidence with clinical judgement and client preferences and values.

Describes treatments that meet a minimum standard of empirical support.

Hallucinations and creativity

Hallucinations and perceptual misrepresentations experienced in certain psychiatric disorders, or resulting from naturally induced ASC, could potentially increase feelings of insight and altered meaning and thus promote creativity. Hallucinations were extensively studied during the 1960s. Heron, Doane, and Scott [1956] observed that aviators sometimes suffer hallucinations during long flights as a result of the monotonous environment. Similarly, American neuroscientist John C. Lilli [1956, 1977] discovered that hallucinations can be spontaneously evoked in sensory deprivation tanks, which isolate participants from sensory input, whereas neurologist Oliver Sacks [2012] reported that many blind people who lost their sight later on in life experience perceptual hallucinations. What do these types of hallucinations have in common and could they be helpful in boosting creativity?

Woodburn Heron [1957] was one of the first scientists to examine this intriguing phenomenon. In his paper “The Pathology of Boredom,” Heron investigated the effect of extended periods of perceptual isolation on cognitive functions. In this study, participants lied on a bed, blinded, in a sound restricted room, wearing cotton gowns to eliminate touch sensations, and had to remain stationary in this position for 24 h for several days [with only short breaks for meals]. Based on subjective statements of the participants in this study, Heron [1957, p. 54] reported that: “Our subjects' hallucinations usually began with simple forms. They might start to "see" dots of light, lines or simple geometrical patterns. Then the visions became more complex, with abstract patterns repeated like a design on wallpaper, or recognizable figures, such as rows of little yellow men with black caps on and their mouths open.” Apart from subjective statements, participants also performed a short cognitive examination before and after the experiment. The test battery included a simple arithmetic task and a word association and suggestibility test. Interestingly, participant performance dropped on all the tasks requiring analytical thinking when compared with the control group, except for measures assessing suggestibility, where the pattern was reversed, namely, participants after isolation became more agreeable to experimenter's proposals for the existence of supernatural phenomena such as ghost or aliens.

What might be the mechanisms underlying such observations? A possible account may be provided by recent predictive coding approaches that characterize perception as more than the passive registration of external stimulus information but, rather, the active testing of perceptual hypotheses based on previous perceptual experience [Friston, 2010]. As suggested by Seth [2014], predictive coding might induce hallucinations by trying to make sense of noisy sensory data in dark environments and/or during sensory deprivation. Hence, in the presence of noisy sensory signals, people may rely on their previous knowledge to deal with the resulting perceptual uncertainty and attempt to generate the best hypothesis for the limited sensory input. From this perspective, perceptual hallucinations may reflect the brain's best guess to interpret perceptual noise.

Alternatively, hallucinations may occur even if sensory information is noise free, as a result of inflated predictions superimposed on sensory data. Such hypotheses were recently supported by artificial neural networks that were able to produce remarkably similar visual effects to those described in psychedelic states or during sensory deprivation experience [Suzuki, Roseboom, Schwartzman, & Seth, 2017]. Namely, Google Deep Dream works with deep convolutional neural networks [DCNNs], which are machine learning algorithms with many hidden layers trained to recognize images [DiPaola, Gabora, & McCaig, 2018]. DCNNs were found to work in similar ways to a primate's visual system, where representations are organized in a hierarchical fashion. DCNNs are organized in layers where the higher-order layers attempt to predict lower-level features processed by early input layers. The Google Deep Dream algorithm inverted the information flow in DCNNs so that the input images change according to higher level predictions. Google Deep Dream was thereafter able to mimic the progression from simple perceptual distortion, such as a change in surface patterning, to more complex hallucinations such as morphing and image misclassifications [DiPaola et al., 2018; Suzuki et al., 2017]. This was achieved by selectively clumping different layers in the network and increasing their predictive power. A recent study by Suzuki et al. [2017] found empirical evidence, suggesting that Google Deep Dream implemented in VR system induces qualitatively similar perceptual experiences to classical psychedelics and other types of ASC.

Some scientists have speculated that creativity or novel insights are by-products of spontaneous predictions that arise in the absence of appropriate sensory signal [Wiggins & Bhattacharya, 2014]. These associative predictions can give rise to “aha-moments,” where one's mind connects ideas from previously unvisited conceptual spaces [Kounios & Beeman, 2009]. In ASC, the distortion of brain mechanisms, or noisy sensory input, stimulates top-down predictions to make sense of the environment. This effect is likely to induce cognitive flexibility where different perspectives and connections can be considered and ultimately improve the repertoire of possible representations, thus enhancing creativity. In other words, an increase in flexibility and misclassifications could explain the purported ability to see many viewpoints at the same time under ASC. Similarly, Ritter and Dijksterhuis [2014] reviewed evidence showing that creative insights often follow the stage of incubation, where one disengages from task-related thought and engages in an unrelated activity such as mind wandering or sleeping. This is because such incubation period might lead to a wider consideration of associative phenomena that would be normally missed. However, it is possible that misclassifications are mistaken for creativity because of their novel/unusual qualities yet they may not translate to everyday practical creativity. Indeed, creativity may be too specific a construct to benefit from enhanced prediction as such. And yet, the relationship between hallucinations and creativity seems worth investigating more systematically.

Launay-Slade Hallucinations Scale [LSHS]

The LSHS is one of the most widely used scales in research and has been frequently modified by researchers wanting to highlight specific aspects of the hallucinatory experience, meaning there are several validated versions in circulation. The initial version was a 12-item scale that involved yes/no responding [Launay & Slade, 1981] but was subsequently modified to include a 5-point Likert scale response to allow each item to be rated on frequency of occurrence [Bentall & Slade, 1985]. A subsequent version expanded the items to 24 and included additional questions on auditory and visual hallucinations, vividness of mental imagery, and day dreams [Morrison et al., 2002]. Subsequent versions have included additional questions on hallucinations in other sensory modalities [Larøi et al., 2004; Larøi & Van der Linden, 2005]. In all versions, the Launay Slade has the advantage of being brief although lacks any distress or functioning based measure and tends towards including items most associated with hallucinatory experience associated with psychiatric disorders.

Schizophrenia

Researchers have proposed various metacognitive conceptualizations of hallucinations and delusions. One early model focused on the role of general metacognitive beliefs about thoughts. As background, some researchers suggest that hallucinations reflect misattributions of internally generated thoughts to external sources [Morrison, Haddock, & Tarrier, 1995]. Similarly, delusions may reflect culturally inappropriate misattributions of internal sensations, thoughts, and emotions [Morrison, 2001]. Examples of delusional misinterpretations include interpreting intrusive thoughts as evidence of thought insertion or intrusive impulses as evidence of alien control. Drawing on a metacognitive model, Morrison [2001] proposed that psychosis-prone individuals likely have strong metacognitive beliefs about the benefits of controlling thoughts and the dangers of uncontrolled thoughts. When these individuals have intrusions that conflict with their metacognitive beliefs about the importance of controlling thoughts, cognitive dissonance is created. In order to reduce this dissonance and the associated emotional discomfort, individuals are motivated to misattribute intrusions to external and/or unrealistic sources, leading to the perception of hallucinations and/or delusions. In addition, these metacognitive beliefs about thoughts may also contribute to use of CAS strategies in response to intrusions.

Some research supports this conceptualization. For instance, greater endorsement of positive and negative metacognitive beliefs, particularly negative beliefs about the need to control thoughts, is associated with hallucination- and delusion-proneness in nonclinical samples [Goldstone, Farhall, Thomas, & Ong, 2013; Larøi & Van der Linden, 2005; Morrison, Wells, & Nothard, 2000]. Similarly, schizophrenic patients with auditory hallucinations and patients at high risk for developing psychosis report more metacognitive beliefs than do nonpatients [Baker & Morrison, 1998; Morrison, French, & Wells, 2007; Morrison & Wells, 2003]. Moreover, positive and negative metacognitive beliefs are associated with greater use of CAS coping strategies in psychotic participants [Sellers, Wells, Parker, & Morrison, 2018]. Patients with psychosis use CAS coping strategies more than healthy control participants. However, several studies have found that the associations between general metacognitive beliefs and psychotic symptoms decrease or disappear when controlling for comorbid symptoms and negative affect [García-Montes, Cangas, Pérez-Álvarez, Hidalgo, & Gutiérrez Martínez, 2005; Goldstone et al., 2013; Varese & Bentall, 2011]. In addition, negative metacognitive beliefs—particularly belief in the need to control thoughts—predict emotional distress in schizophrenic patients over and above the effect of psychotic symptoms [Austin et al., 2015; Sellers, Gawęda, Wells, & Morrison, 2016; van Oosterhout, Krabbendam, Smeets, & van der Gaag, 2013]. Thus, general metacognitive beliefs about thoughts might be more strongly related to distress associated with psychotic experiences, rather than representing a contributing factor to the symptoms themselves.

More recent theorizing focuses on metacognitive beliefs specifically about psychotic symptoms. For instance, Wells [2007a] suggested that people may hold positive beliefs about hallucinations, such as the perceived benefits of companionship or comfort. These types of positive beliefs may make people more likely to engage with hallucinations. On the other hand, negative metacognitive beliefs involve auditory hallucinations being powerful, omnipotent, and/or malevolent and that these experiences threaten one’s physical or psychological integrity. These negative beliefs may trigger emotional distress and unhelpful coping [CAS] responses, such as rumination, worry, threat monitoring, and suppression, all of which likely contribute to more intrusions. Similarly, Morrison argued that positive metacognitive beliefs about delusions [e.g., paranoid ideas may add meaning to life, provide excitement, or function as a survival strategy in response to trauma; grandiose ideas make people feel important] make people more likely to make delusional misinterpretations [Morrison, 2001; Morrison, et al., 2005]. Similarly, negative metacognitive beliefs about the danger and uncontrollability of delusions may be related to distress, trigger other CAS strategies, and predict patient status. As an example of this process with paranoid delusions, a triggering situation event [e.g. seeing a young man while shopping] could activate positive metacognitive beliefs about paranoia helping to cope with the perceived threat [e.g., “It is important to be alert for danger in order to survive”], which in turn might lead to specific paranoid thoughts [e.g., “That man is going to attack me”]. The experience of paranoia can activate negative metacognitive beliefs about paranoia [e.g., “My paranoia is uncontrollable”], leading to emotional distress and attempts to control or avoid paranoia [Murphy et al., 2016].

Empirical evidence supports the role of symptom-specific metacognitive beliefs. In healthy college students, positive metacognitive beliefs about hallucinations are associated with greater tendencies for auditory and visual hallucinations [Morrison et al., 2000]. Similarly, both positive and negative beliefs about paranoia are associated with more paranoia, whereas only negative beliefs uniquely predict distress from delusions [Morrison et al., 2005]. Patients with schizophrenia spectrum disorders report more negative metacognitive beliefs about hallucinations, as well as positive and negative beliefs about paranoia, than do healthy controls [Morrison et al., 2011; Morrison, Nothard, Bowe, & Wells, 2004; Morrison & Wells, 2003]. Positive beliefs about paranoia are associated with more severe paranoia [Morrison et al., 2011], whereas negative beliefs about hallucinations and paranoia are particularly associated with distress from these symptoms [Morrison et al., 2004; Murphy et al., 2016]. Unfortunately, no research has examined the association between symptom-specific metacognitive beliefs and the use of CAS strategies in psychotic patients.

A few case studies have examined the efficacy of MCT or its components in psychotic patients. For instance, ten patients with schizophrenia spectrum disorders received 12 sessions of MCT [Morrison et al., 2013]. The treatment did not directly target hallucinations or delusions but instead focused on helping patients reduce their use of CAS strategies [particularly repetitive thinking], developing more adaptive coping strategies, and changing their metacognitive beliefs. Group-level analyses indicated that MCT led to significant reductions in positive symptoms posttreatment and three months later. Both positive and negative metacognitive beliefs decreased posttreatment. However, there were no significant differences in negative symptoms or general emotional distress. In another study, MCT led to large and clinically significant reductions in psychosis and metacognitive beliefs in two out of three patients with treatment-resistant schizophrenia [Hutton, Morrison, Wardle, & Wells, 2014]. Similarly, eight sessions of stand-alone ATT led to reduced symptoms and metacognitive beliefs in one patient with treatment-resistant schizophrenia [Valmaggia, Bouman, & Schuurman, 2007].

Treat delirium symptoms—distress, agitation, psychotic symptoms

Agitation, psychotic symptoms as illusions or hallucinations are rather common in hyperactive delirium. Distress could be undetected in patients with hypoactive delirium types as they rarely report it. Other sources of discomfort must be ruled out [pain, urinary or stool retention]. Calm environment, frequent reassurance and reorientation techniques or verbal and nonverbal de-escalation techniques may be effective in most patients. Sometimes more frequent encounter with family members may be helpful. Agitated and distressed patients should be frequently monitored and if needed permanently supervised [use of teletechniques or special delirium units with sufficient staff and safe environment have been piloted so far].

An effective management technique has been described “The T-A-DA method” [Tolerate, Anticipate, Don’t Agitate] [Flaherty and Little, 2011]. Patient behavior is tolerated even if not appears normal until it does not cause harm to self or others. This method requires a specifically designed “delirium unit” for older patients with delirium. Adverse and agitated behavior is anticipated, and measures taken to reduce agitation or disteress [in some cases it means not to reorient the patient].

If nonpharmacological measures do not help, medication is the second-line treatment option.

Introduction

Although the positive [i.e. delusions and hallucinations], negative [i.e. anhedonia or avolition] and disorganised symptoms [i.e. bizarre thinking] are distinct features of schizophrenia and related psychotic disorders, a decline in everyday functioning and quality of life is one of the core deficits of the illness [Harvey, Heaton, et al., 2012; Harvey, McClure, et al., 2012; Harvey & Strassnig, 2012; see Box 18.1 for a case example]. Social functioning comprises essential skills required to successfully live in society, such as independent living [e.g. cleaning, hygiene, cooking, etc.], engaging in social relationships [e.g. social skills], and abilities in education and work [Lecomte, Corbière, & Briand, 2008]. The impairment of day-to-day functioning accompanying psychotic illness accounts for much of the social, personal, and economic burden [Trautmann, Rehm, & Wittchen, 2016]. Societal costs of poor psychosocial outcome in schizophrenia are estimated in billions per year, signalling a pressing public health concern [Trautmann et al., 2016; Wu et al., 2005]. It is critical to understand the mechanisms that lead to poor functional recovery.

Box 18.1

Case Study: TJa

TJ is a Caucasian 21-year-old male. Role functioning: TJ started his second year at college in September, studying a major in economics and minor in Spanish. Throughout the previous year, TJ had A's and B + grades on average. However, TJ reports that he recently commenced smoking cannabis often and playing video games all night with his roommate. With his sleeping pattern inversed, he spent most of the day sleeping. Accordingly, he missed several assignments and his grades starting dropping. He felt his mood was very low and did not want to interact with classmates or lecturers to follow up with the assignments. TJ stated, ‘I felt as though I lost all my motivation’. TJ was employed 1 day a week in the university sports center helping with the gear rental. In February, he began a leave of absence from work because ‘it was too stressful and I had to deal with too many students’.

Social functioning: TJ reports having several friends at the beginning of the year [around 10 close friends and multiple acquaintances]. TJ was living on a dorm, where he shared a room with a friend. TJ was also part of a fraternity and the soccer team, seeing his friends out of college multiple times a week. TJ had been in a relationship with his girlfriend for nearly 2 years. However, TJ felt that due to his low mood, he began to push people away. He stated that he went from having a large group of friends to one close friend, his roommate, with whom he smoked cannabis on a daily basis. Because friends insisted in trying to hang out with him, TJ had some significant conflict with them. Moreover, TJ stated that his friendship with his roommate drifted after a fight regarding personal space and TJ's suspiciousness regarding his belief of hidden cameras in the room. TJ also shared that he had problems with his girlfriend, as he believed that she had been unfaithful. As such, things became ‘rocky’, and conflict increased between TJ and his partner. He reports that those months were very stressful, and now TJ and his partner are currently on a break. TJ explains that he feels he has lost interest in dating.

After progressive isolation, growing loneliness, and withdrawal from studies and work, TJ moved back to his family home. Now he lives with his parents, although these relationships are also difficult. TJ reports that they forced him to leave college as a means to control him and spy on him, as his bedroom ‘is not exactly as it used to be’. He is sure that his parents have installed cameras in the room, and he tries to avoid contact with his parents as much as possible. TJ currently spends most of his time alone playing video games, rarely leaving his room.

Decline in social functioning is a core difficulty observed in people with schizophrenia spectrum disorders.

There are several hypothesised pathways to poor psychosocial functioning in schizophrenia, which are not mutually exclusive. One model states that poor psychosocial functioning may be an early indicator of a neurodevelopmental and chronic illness—probably of genetic origin [Harvey, Heaton, et al., 2012; Harvey, McClure, et al., 2012]. Because psychosocial impairment is usually observed before the onset of illness, this would support the theory. An alternative explanation is that psychosocial functioning could be the consequence of factors related to the onset of illness [i.e. anxiety, depression, stigma, substance use, and a decrease in socialisation; Killackey & Yung, 2007]. There is evidence supporting this view, as psychosocial functioning deteriorates at the same time as symptoms of psychosis develop [from hereon we will use the term psychosis to comprise schizophrenia and schizophrenia spectrum disorders]. Poor functioning is also observed accompanying subthreshold symptoms in the prodromal phase of psychosis, with youth at clinical high risk for psychosis showing poorer social functioning than healthy controls [Addington et al., 2011]. Accordingly, psychosocial functioning could be improved after treating these associated symptoms. Cornblatt et al. [2003] suggested a neurodevelopmental model proposing that the well-known vulnerability for psychosis comprises deficits in four—necessary but not sufficient—domains: Cognitive-Affective-Social-Isolation-School/work problems [referred to as the ‘CASIS’ cluster]. From this view, deficits in these domains are a precondition for the development of psychotic disorders, particularly schizophrenia, and positive symptoms are an independent process that would progress to a chronic course of illness [i.e. schizophrenia] in the presence of deficits in CASIS.

Poor psychosocial functioning may be a cause, correlate, or consequence of illness in people with psychosis.

The stability of poor functioning over the course of illness remains a critical clinical concern. Although the majority of first-episode psychosis [FEP] individuals [around 75%] achieve remission of their positive symptoms after antipsychotic medication [Cassidy, Norman, Manchanda, Schmitz, & Malla, 2010], functional recovery does not occur in the same way. One of the frequent consequences of the onset of psychosis is a downward spiral of loneliness and disconnection from the community and peers, interruption of hobbies and school, and difficulties in work-related activities directly affecting long-term well-being [Penn, Waldheter, Perkins, Mueser, & Lieberman, 2005]. FEP youth may remain isolated with poor social functioning [Lieberman et al., 1993]. Specifically, FEP youth have smaller support systems [Macdonald, Hayes, & Baglioni, 2000], social networks [i.e. youth are 5–9 times less likely to have close friends compared with their healthy controls counterparts; Morgan et al., 2008], and they report feeling lonely 35% of the time [Sündermann, Onwumere, Kane, Morgan, & Kuipers, 2014].

Loneliness and social isolation are common in people with, or at increased risk for, psychotic disorders.

Symptom remission helps short-term functional recovery, but it is not enough, nor necessary [Alvarez-Jimenez et al., 2012]. Because functional recovery is not usually achieved with symptom remission after antipsychotic medication, poor functioning often remains stable from illness onset [Cornblatt et al., 2003]. In fact, less than 15% of individuals with psychosis show adequate functioning 5 years after the first episode of illness [Patterson, Moscona, McKibbin, Davidson, & Jeste, 2001]. For example, the majority of individuals with schizophrenia do not achieve normative milestones in self-care, work, and social functioning such as marriage or stable relationships [Harvey & Bellack, 2009]; most have markedly reduced social networks [Patterson et al., 1997], and limited socially oriented activities. Moreover, competence in social skills is usually impaired in individuals with schizophrenia [Patterson et al., 2001]. Additionally, a feature of poor functioning comprises socially disruptive behaviour [i.e. intrusive requests, inappropriate questions and comments, impairment in the tone or volume of voice, speech deficits, and impaired judgement of interpersonal distance; Harvey, Heaton, et al., 2012; Harvey, McClure, et al., 2012]. Furthermore, not only the quality and quantity of interactions are reduced, the motivation to interact [i.e. social motivation] is also greatly diminished.

Positive Symptoms

Positive symptoms encompass psychotic symptoms such as delusions and hallucinations. Delusions are fixed, false beliefs that are not consistent with one's culture. Hallucinations are perceptual disturbances in the absence of external stimuli. An example of a delusion may be if you believe that the government is monitoring your every action through a microchip inserted in your brain, despite all objective evidence being contrary to this belief. Likewise, a hallucination may present as an experience of hearing a derogatory voice describing your every action, even when there is nobody around you. These are called positive symptoms because they are added to one's usual experiences. It is important to recognize that even though the positive symptoms or psychosis are intimately associated with schizophrenia and also with the concept of “madness,” they are not the same thing. A wide range of mental disorders from anxiety spectrum disorders to bipolar disorder can have psychotic symptoms as part of their clinical presentation [van Os and Kapur, 2009; Kelleher and Cannon, 2016]. In fact, psychotic experiences are reasonably common, albeit infrequent, even in the general population [i.e., people with no mental disorders; McGrath et al., 2015].

The problem

Psychotic disorders are devastating mental illnesses characterized by hallucinations, delusions, and disorganized thinking [American Psychiatric Association and American Psychiatric Association. DSM-5 Task Force, 2013]. Despite a population prevalence of less than 1% [Moreno-Kustner, Martin, & Pastor, 2018; Saha, Chant, Welham, & McGrath, 2005], schizophrenia and other psychotic disorders account for 13 million disability-adjusted life years globally [Charlson et al., 2018] and may cost as much as $100 billion annually in the US due to medical expenses, lost productivity, and premature mortality [Chong et al., 2016]. Schizophrenia reduces an individual's lifespan by approximately 20 years due to poor lifestyle, cardiometabolic disease [e.g., diabetes, obesity, hypertension], minimal social support, adverse medication events, and a 40% suicide attempt rate [Fuller-Thomson & Hollister, 2016; Laursen, 2019; Olfson, Gerhard, Huang, Crystal, & Stroup, 2015; Seeman, 2019].

Disrupted sleep features prominently in psychotic disorders. Half of the individuals with schizophrenia report insomnia symptoms, 48% have a nightmare disorder, another 30% have hypersomnia, and 15% have obstructive sleep apnea [Stubbs et al., 2016; Waite, Sheaves, Isham, Reeve, & Freeman, 2020]. Circadian rhythm disturbances are also common and may affect as many as 50% of patients [Afonso, Figueira, & Paiva, 2014; Wulff, Dijk, Middleton, Foster, & Joyce, 2012]. Moreover, these disorders are often comorbid; one study reported an average of three disorders per patient [Reeve, Sheaves, & Freeman, 2019]. Addressing these sleep disturbances is critical because the cost of poor sleep in psychosis is nontrivial. Insomnia triggers hallucinations and delusions, reduces the quality of life, and increases the risk of suicide [Li et al., 2016; Miller, Parker, Rapaport, Buckley, & McCall, 2019; Mulligan, Haddock, Emsley, Neil, & Kyle, 2016; Reeve, Sheaves, & Freeman, 2019; Waite et al., 2020]. Additionally, disrupted sleep in psychosis likely contributes to or exacerbates cardiometabolic disease as has been demonstrated in other populations [St-Onge et al., 2016].

Behavioral sleep medicine can significantly improve these sleep disturbances. A pilot trial of CBT-I in the United Kingdom substantially improved insomnia in patients with psychotic illness [Freeman et al., 2015], and similar results were shown in a nonrandomized trial in South Korea [Hwang, Nam, & Lee, 2019]. Furthermore, treating insomnia may reduce psychotic symptoms [Bradley et al., 2018], although larger studies are needed to confirm this finding. For inpatient settings, traditional CBT-I can be modified to a brief, intensive format with reasonable results [Sheaves et al., 2018]. Additionally, the Transdiagnostic Sleep and Circadian Intervention [Trans-C] [Allison G. Harvey & Buysse, 2018], which addresses the broader issues of sleep/wake dysregulation in psychiatric illness, represents an exciting new opportunity to improve sleep in psychotic disorders.

While patients [Faulkner & Bee, 2017; Waite et al., 2016; Waite et al., 2018; Waters, Chiu, Janca, Atkinson, & Ree, 2015] and providers [Rehman et al., 2017] acknowledge insomnia as a significant problem, sleep is often assessed informally and treated using sleep hygiene interventions, sedative medications, or not at all [Hou et al., 2017; Rehman et al., 2017]. This is troubling because [1] medications are not an effective long-term solution for insomnia [Sateia, Buysse, Krystal, Neubauer, & Heald, 2017], and [2] patients often express a preference for behavioral/psychological treatment of insomnia [Faulkner & Bee, 2017; Waite et al., 2018; Waters et al., 2015]. Consequently, access to CBT-I in this population remains poor.

Common Symptoms

Symptoms of psychosis are culturally mediated. Studies have reported hallucinations in 0.6%–84% of the general population [median of 13.2%] [Beavan, Read, & Cartwright, 2011; Larøi et al., 2014]. Delusion-like beliefs, too, may be widespread [Pechey & Halligan, 2011]. Delusional beliefs may be secular [being infested by parasites, being exceptionally gifted, etc.] or religious/spiritual [reincarnation, communicating with spirits, etc.]. Their content is influenced by cultural paradigms. The negative views of hallucinations and delusions in Euro-American culture may suppress their reporting [Al-Issa, 1995]. Clinicians must interpret reported hallucinations and delusions within cultural contexts before concluding that they constitute signs of psychosis. Bizarre, unpleasant or horrific experiences are likelier indicative of psychoses. Brief, uplifting experiences [especially in the context of grief or trauma] that are neither secretive nor cultural outliers are less likely to be pathological. Time spent to understand psychotic symptoms in cultural context is worth the extra effort. It is crucial, though, not to assume that a client is the same as others of their linguistic, religious or historical tradition. Evaluating the presence of psychotic symptoms must be a culturally informed but person-centred process [see Vignette #1, Box 4.1].

Box 4.1

Vignette #1a

A 25-year-old Haitian refugee claimant explained that she was chosen in childhood by a “loa” [spirit] to become the family spiritual leader. She realized this through a vision in which people performed a night song. She regretted not having chosen to “sit the spirit,” who was a trickster being wooed by her brothers. She doubted her own chosen status and thought her older brother was better prepared for the role. While she desired stronger faith to accept the loa and usher in peace and prosperity [Voodoo worldview], she also felt the need to work hard to get things for herself [Protestant worldview].

Comment: Given this narrative and the presence of insomnia, agitation, erratic decision-making and socio-occupational decline, such a person could easily have been prematurely or erroneously diagnosed with psychosis. However, a psychosis diagnosis is withheld when the culture broker says, ‘That's what we talk about all the time in Haiti’. This case illustrates the complexities of cross-cultural diagnosis and symptom interpretation, especially among patients negotiating hybrid identities [Voodoo-African and Protestant-European, in this case].

Developing a culturally appropriate understanding of your client takes time.

Developing a culturally appropriate understanding of your client takes time. When working with interpreters, allow a 2-hour intake interview. Invite family members to participate if they haven’t initially. Take the time to inquire about the family understanding of the client's symptoms. What kinds of treatments would they expect to be helpful? Patiently gathering information will pay dividends over the long-term.

Discussion

The two cases presented here demonstrated an increase in the occurrence of hallucinations during, compared to before, the Covid-19 lockdown. This increase can be attributed to several factors such as social distancing, as implemented by the nursing home in which the two cases are living. Social distancing and isolation may lead to spatiotemporal orientation, anxiety, and increasing somatic discomfort which may lead to stress reaction and hallucinations. The nursing home where the two cases resided [as did other facilities on a national level] implemented strict social distancing measures and drastic changes in the daily life of the residents from March 16th 2020 to April 25th 2020. Nonessential activities and services [e.g., hairdressers] were restricted, including basic social activities such as communal dining. Residents were invited not to leave their wards; however, when they did so, they were asked to keep a safe distance from other residents in order to avoid contracting the virus. Critically, residents were not allowed to have any physical contact with their family members and friends. In the case of Mrs. L, her daughter used to visit her once per week before the lockdown, but was not able to visit her during the lockdown. Regarding Mrs. C, her two sons used to visit her once to twice per week before the lockdown, but were not able to visit her during the lockdown. In addition, due to their cognitive decline, as observed on the cognitive evaluation, both Mrs. C and Mrs. L were not able to use the current technology [e.g., Skype] to get in touch with their children or grandchildren. The only contact occurred by phone.

While the [physical] social restrictions, as implemented by nursing homes, may be deemed necessary in order to avoid Covid-19 infections, these restrictions are likely to come at a cost to residents in retirement homes by affecting their mental health. The decrease in social activities in the facilities and the decrease in physical contact with family members may increase loneliness, itself leading to hallucinations. This assumption can be supported by research demonstrating how hallucinations in patients with AD can be associated with loneliness [El Haj et al., 2016]. To compensate for boredom and emptiness, as this is associated with loneliness, patients with AD may generate internal stimuli to fulfill their need to communicate [El Haj et al., 2016]. In other words, hallucinations in patients with AD can be regarded as a compensatory mechanism that aims to fulfill their communicatory needs [El Haj et al., 2016]. These hallucinations can also be attributed to confusion or diminished orientation in time. Because of the lack of visits and social activities, patients can get bored and feel time passing very slowly. Patients can therefore generate hallucinations to fill this temporal emptiness. While this assumption is clinically appealing, it should be considered with some caution as our study did not include an evaluation of time perception.

The assumption that social restrictions, as implemented during the Covid-19 crisis, may affect the mental health of patients with AD can be supported by two recent studies. The first study included patients living in retirement homes and the second study included patients living in their own homes. In the first study [El Haj, Altintas, Chapelet, Kapogiannis, & Gallouj, 2020], patients with mild AD living in retirement homes were invited to rate their depression and anxiety during and before the Covid-19 crisis. Participants reported higher depression and anxiety during than before the Covid-19 crisis. The increased distress was attributed to the isolation of the residents and/or to the drastic changes in their daily life and to the care they receive in the retirement homes during the crisis. The effect of confinement on mental health of patients with AD was also reported by a study demonstrating increased neuropsychiatric symptoms in patients with AD who were confined in their own homes during the Covid-19 crisis [Boutoleau-Bretonnière et al., 2020]. In this study, caregivers were invited to report whether patients experienced increased neuropsychiatric symptoms during the confinement and, if it was the case, to rate this increase. Results demonstrated increased neuropsychiatric symptoms only in patients with advanced AD and this increased symptomatology significantly correlated with the duration of confinement.

To summarize, while the lockdown in retirement homes during the Covid-19 crisis is necessary in order to prevent infection, this lockdown may negatively impact the wellbeing and mental health of residents. The decrease in daily activities and social contact during the lockdown, as well as the physical separation of residents from loved ones, may lead to confusion, despair, and loneliness. Ultimately, the lockdown may increase hallucinations in residents, at least in those who were already experiencing hallucination prior to the lockdown. Research on a large scale is required to further investigate the effects of Covid-19 lockdown on hallucinations in patients with dementia living in nursing homes.