Pseudohallucinations: A Pseudoconcept?

A Review of the Validity of the Concept, Related to Associate Symptomatology

Roy van der Zwaard and Machiel A. Polak
Pseudohallucination is a concept used in the classication of nonpsychotic perceptual disorders. This report describes the history of the concept and investigates whether pseudohallucinations can be differentiated from related psychopathological symptoms, such as hallucinations, re-experiencing, and dissociative phenomena. We performed a literature review, which shows that pseudohallucinations and related symptoms have low construct validity and are, accordingly, clinically ambiguous. Most likely, pseudohallucinations are placed on an overlapping continuum of symptomatology that includes perceptual disorders, re-experiencing, (dissociative) imagery, and normal thought and memory processes. Recommendations are made regarding the specication of dimensions of this continuum. The term nonpsychotic hallucinations is preferred over pseudohallucination. Copyright 2001 by W.B. Saunders Company

LTHOUGH PSEUDOHALLUCINATION is a commonly used descriptive entity in clinical practice and forms an integral part of the standard mental status examination, a straightforward operational denition of the construct is missing. Dening and Berrios1 showed that a majority of psychiatrists considered the notion to be confusing and clinically not useful. Psychiatrists who did use the concept, predominantly did so inconsistently. The aim of this review is to investigate whether pseudohallucinations can be operationalized and, if so, can make a contribution to a more systematic mental status examination by increasing the comprehensiveness, interchangeability, and reliability of psychiatric observations. Semantically, pseudohallucination can be considered a contradictio in terminis (a false perceptual disorder), which might partially account for the confusing status of the concept. As yet, pseudohallucinations have been described in the literature as (1) perceptual disorders without sensory vividness,2 (2) hallucinations with intact reality-testing and insight,3 and (3) isolated hallucinations (without additional psychopathology) that do not t in any other diagnostic category.4 Furthermore, it is unclear whether there is (dis)continuity with hallucinations, or whether it is a form of (normal) imagination,5 voluntarily or not.
From the Department of Psychiatry, Academic Medical Centre, Amsterdam, The Netherlands. Current address: Rijngeest Group of Mental Health, Noordwijk, The Netherlands. Address reprint requests to Roy van der Zwaard, MD, Anton Constandsestraat 36, 1097 HX Amsterdam, The Netherlands. Copyright 2000 by W.B. Saunders Company 0010-440X/00/4201-0008$10.00/0 doi:10.1053/comp.2001.19752
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In 1996, Berrios and Dening6 published a conceptual history on this subject. However, in this review, we will mainly investigate the discriminant validity of the concept. Therefore, we will try to differentiate pseudohallucinations on phenomenological and descriptive criteria from other experiences in which an adequate, actual external stimulus is absent, such as in hallucinations, imagination, obsessions, re-experiences, and dissociative phenomena. Next, we will discuss the consequences for the validity and use of the concept of pseudohallucinations. Etiological and pathogenetic explanations of pseudohallucinations, such as from psychodynamics, neurobiology, and informationprocessing theories, are outside the scope of this review.
METHOD
A Medline search from 1986 to current using pseudohallucinations as a key word provided us with 12 articles. ClinPsyc does not include pseudohallucinations as a keyword. Subsequently, both databases were searched for the keyword hallucinations, successively in combination with dissociation, obsessions, imagery, post-traumatic stress disorder (PTSD), re-experiences, memory, and self-talk. In addition, salient references from obtained articles were followed up on. Phenomenological descriptive standard textbooks (Bleuler, Kraepelin, Jaspers and, much newer: Kaplan & Sadock and DSM-IV) were screened for the same keywords. All literature was descriptive and/or conceptual in nature, with the empirical study by Sedman7 as the only exception.

RESULTS

Genesis of the Concept The expression pseudohallucination was rst introduced by Hagen8 in 1868, in his German writing Zur Theorie der Halluzinationen (On Theory of Hallucinations), and elaborated by Kandinsky9 in 1885, as the need was felt to distinguish perceptual phenomena in psychotic syndromes from other

Comprehensive Psychiatry, Vol. 42, No. 1 ( January/February), 2001: pp 42-50

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clinical pictures. To derive at a denition of pseudohallucinations, they drew heavily on the debate about hallucinations held in France over the previous 20 years, which resulted in the consensus that, besides pathological hallucinations, psychic/physiologic/mystic hallucinations also existed. Absence of insight and external localization of the experiences contributed to the pathological character of hallucinations as they were seen in schizophrenia (primary madness). Goldstein and Jaspers continued the conceptual discussion at the start of this century. Goldstein10 proposed that the notion of pseudohallucinations was only justied when reality testing remained intact. Bleuler11 followed Goldstein in stating: Perceptions with complete sensory clearness and normal localization of which the deceptive character is noticed, are called pseudohallucinations. Jaspers5 criticised Goldstein sharply and rejected reality testing as the crucial variable, as it reected the appraisal of a perception rather than an intrinsic aspect of the perception. In Jaspers view, discriminating pseudohallucinations from hallucinations is purely a matter of Sinnlichkeit (sensory vividness, freshness) and the almost untranslatable notion of Leibhaftigkeit, by which is meant literally form of palpability (corporeality): When we take normal representations (Vorstellungen) and add to them more and more characteristics of perception such as independence of volition, clarity, and detail, but not corporeality, we arrive at pseudohallucinations. Jaspers assigned pseudohallucinations to imagination, representation, and thought disorders which are separated by an abyss from perceptual disorders. Furthermore, these representations were considered to possess a spontaneous quality, which is to say that they could not be produced or altered by will. Subsequent authors followed Goldsteins or Jaspers concepts, or combined them, as did Taylor,3 who postulated that there are two types of pseudohallucinations: perceived (hallucinations with insight) and imaged (vivid internal imagination). Sedman,7 in the only empirical study on pseudohallucinations, examined 72 patients and found that both imagery (internal localization, low sensory vividness) and pseudohallucinations (sensory perception, with intact reality testing) were associated with unstable personality rather than psychotic illness. The Present State Examination (PSE)12 dened

pseudohallucinations as voices coming from within the mind, as opposed to originating from the outside world. Never before had this criterion been dened so explicitly, although it may have had its roots in the work of Sedman.7,13 The idea of pseudohallucinations is slightly modied in the PSE successor, the Schedules For Clinical Assessment in Neuropsychiatry (SCAN)14: internal hallucinations (which may be called pseudohallucinations, although this phrase can also be used differently) are inner voices or images which are as concrete and vivid as hallucinations. They are experienced within the mind (i.e., inside the head), cannot be evoked or changed, with or without insight present. The assumption of a clear distinction between the types (internal or external) is somewhat articial. The Composite International Diagnostic Interview (CIDI)15 does not include the pseudohallucination concept. As a result, an entire generation of psychiatrists (to this day) was inuenced by the PSE denition in their understanding of pseudohallucinations. Kaplan and Sadock16 assigned the concept to the class of perceptual disorders: perceptions experienced as coming from within the mind, as well as hallucinations whose validity the patient doubts, for which they recommend the phrase partial hallucinations, analogous to partial delusions. In the recent literature, the concept of pseudohallucinations is rarely mentioned. Since 1986, in addition to three review articles,6,17 only nine articles include pseudohallucinations, in widely different denotations. Pseudohallucinations as a result of partial sensory deprivation (e.g., visual or auditory impairment) or neurological disorders (e.g., epilepsy and migraine) receive increasing attention. Disorders of the peripheral sensory systems typically produce ill-formed, simple perceptions (e.g., photopsias: stripes, stars, colors). Sometimes the term is reserved for drug-induced psychosis or for the unusual phenomenon that radiosignals are conducted by dental llings or shrapnel fragments in the patients skull.2 Differentiation From Other Psychopathological Symptoms To the extent that there is any consensus about the denition of pseudohallucinations, it appears to be focused on two qualities: (1) pseudohallucinations are perceptions, experienced within the mind (with or without sensory vividness); and/or (2)

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pseudohallucinations are considered hallucinations with intact reality testing. Can pseudohallucinations be differentiated from other psychopathological symptoms on the basis of these qualities? In other words: what can we say about its discriminant validity? Differentiation From Hallucinations (Table 1) Pseudohallucinations often are dened in negatively: as experiences that resemble but are not identical to hallucinations.1 The denition of pseudohallucinations is thus interdependent with the validity and reliability of the hallucinations concept. In general, hallucinations are considered experiences that (1) occur in the absence of a corresponding sensory stimulus, (2) occur involuntarily, and (3) are considered real by the hallucinator. From a phenomenological perspective, hallucinations cannot be discriminated from normal perceptions, i.e., real perceptions and hallucinations can have identical characteristics.18 These characteristics include vividness, complexity, involuntariness, and external localization.19 In the general population, 10% to 25% ever experience hallucinations, mostly of an auditory or visual nature. Familiar hallucinations are hypnagogic and hypnapomp experiences, and auditory hallucinations in normal grief reactions.20 Consequently, hallucinations cannot be considered a sign of psychopathology per se; they are relatively nonspecic. Even though certain forms of hallucinations occur more often in certain conditions (i.e., as a result of alcohol or drugs abuse), these forms cannot be considered pathognomonic.18 Seventy-ve percent of schizophrenic patients ever experience
Table 1. Characteristics of Hallucination
Variable Hallucinations

Auditive Visual Haptic Olfactory Gustatory Localization Vividness Reality testing Continuity over time Functional result Control Secondary delusions Cue-triggering Other

Often Sometimes Rarely Rarely Rarely Often external From lifelike to as-if character Impaired Yes Often anxiety-provoking No Often Sometimes Often bizarre dreamlike

(functional) hallucinations. Most often these are auditory hallucinations that take the form of voices speaking to each other or addressing the patient in an often devaluating, imperative, or commenting fashion. The voices are often familiar to the patient and can vary in number, gender, and localization (inside or outside the head). Interference with processing of other auditory stimuli is possible. The voices are often anxiety-provoking and can trigger secondary delusions. Stress and anxiety can result in an increase of hallucinations.21 The content of hallucinations is often emotionally charged. Over the last 10 years, much progress has been made by the neurosciences (neuropsychology, neurochemistry, neuroanatomy) in understanding the development of hallucinations. However, neuroscientic hypotheses remain quite speculative22-24 and fall outside the scope of this report. To investigate the validity of purported characteristics of pseudohallucinations, we will try to differentiate them from qualitative parameters of hallucinations. Internal localization of voices does not discriminate between pseudohallucinations and hallucinations. Pennings and Romme25 compared three groups of people hearing voices: schizophrenics, patients suffering from dissociative disorders, and nonpatients (i.e., without psychiatric classication). All three groups reported hearing voices inside their head, as well as originating from the outside world, and voices were predominantly considered egodystonic. The hallucinations were mainly experienced in second person singular across the three groups. Commenting voices dominated slightly in schizophrenia. In sum, these formal characteristics did not adequately discriminate between patients and nonpatients, which was consistent with previous ndings.26 In other words, internal localization of voices does not appear to be an exclusive property of pseudohallucinations. The as-if character of many hallucinations does not discriminate from pseudohallucinations. Particularly mild psychotic symptoms can exhibit an as-if character; It is as if something is crunching in my brain, like a persistent buzzing. While reality testing remains initially intact, it may disappear when the experiences become inescapable.27 In similar fashion, the fading of hallucinations during which the quality of reality testing increases does not change the past or present psychopathological state.

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Hallucinations with intact reality testing are pseudohallucinations by denition. There are multiple states during which experiences share all features intrinsic to hallucinations but in which reality testing remains intact. An example is the auditory hallucination during normal grief reactions in which the voice of the deceased is heard, often with external localization and a high level of sensory vividness.20 Other examples include well functioning normals hearing voices25 and hallucinations in the Charles Bonnet syndrome (CBS). The latter consists of nonanxiety-provoking, complex visual perceptions (e.g., tiny animals or gures) in the elderly with sensory vividness and insight, in the absence of primary or secondary delusions.28 The etiology of CBS is unclear, although a combination of factors seems likely. All hallucinations mentioned above could be considered pseudohallucinations in view of the unimpaired reality testing. Perhaps it is more appropriate to label these experiences as isolated, nonpsychotic hallucinations. DSM-IV descriptions do not adequately discriminate pseudohallucinations from hallucinations. In DSM-IV,29 pseudohallucination is mentioned only once, in describing conversion: hallucinations (pseudohallucinations) generally occur with intact insight in the absence of psychotic symptoms, often involve more than one sensory modality, and have a naive, fantastic or childish content. They are often psychologically meaningful. This is not at all specic to pseudohallucinations: schizophrenic or organic/drug-induced psychosis can produce simultaneous hallucinations of more than one modality, and be characterized by naive, fantastic, or childish content. In these conditions, hallucinations can be kaleiscopical, change from one complex form to another (e.g., a dolphin changing into a submarine), change within a single image (e.g., a mans head gradually swells in size and changes from pink to blue, becomes a balloon and oats away) or can be repetitive (one toy soldier is duplicating and becomes a whole army), etc.30 Overall, pseudohallucinations cannot be adequately differentiated from hallucinations, partly because the latter is too inconsistently and broadly dened. To prevent unnecessary confusion: an illusion5 can be dened as an inaccurate interpretation of real external sensory stimuli (i.e., a bath-

robe is, transiently held for a burglar), while a delusional percept is an expression of a thought disorder and refers to the experience during which normal perceptions are invested with a delusional meaning (e.g., moonlight interpreted as the glowing of the devils eye). Both phenomena are easily discriminated from pseudohallucinations, as there is no external sensory stimulus in the latter. Differentiation From Obsessions and Imagery (Table 2) Pseudohallucinations cannot be differentiated from certain forms of imagery and obsessional imagery. In imagery, repeated imaging of an object (i.e., to call images to mind of an apple or a piece of music) results in similar but not identical images. Only the most typical features are kept in memory.31 Both sensory vividness and internal coherence (i.e., continuity over time) are absent. The experiences are usually voluntary and can be stopped or changed at any time. In 1981, Taylor3 postulated the concept of imaged pseudohallucinations, by which he meant vivid, internal, involuntary imagination, quite similar to Jaspers description early this century: dressed up imagery, lacking the corporeality of hallucinations. To illustrate, the phenomenon of a melody stuck in ones mind meets all criteria of the concept of (im-

Table 2. Characteristics of Obsessions and Imagery

Variable Obsessional Imagery Fantasy and Imagery

Auditive Visual Haptic Olfactory Gustatory Internal localization External localization Vividness Reality testing Continuity over time Functional results

Yes Yes ? ? ? Yes No Lifelike Intact No Anxietyprovoking, wish-fullling No/temporary Possibility Often sexual, or aggressive

Yes Yes Yes No? No? Yes No Low Intact No Supportive, wish-fullling Yes No Also: daydreams

Control Secondary delusions Other

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aged) pseudohallucinations, for it is involuntary, internal, characterised by intact reality testing, and has an as-if character. Another example is obsessional imagery, a specic form of obsession. Obsessions are recurrent, persistent ideas, thoughts, impulses, or images that are egodystonic, which the individual is able to recognize as a product of his/her own mind.29 Obsessional imagery (the compulsion to call images to mind of mutilation, sexual acts, and practices of war) also has a striking similarity to supposed characteristics of pseudohallucinations. Reality testing remains intact, but in contrast to normal imagery, sensory vividness is high and the experiences are almost involuntarily.32 However, the term pseudohallucination is confusing: obviously the phenomenon relates to a thought or imagery process, rather than a perceptual disorder, under which pseudohallucinations are classied. Overall, it becomes apparent that there likely exist smooth transitions between thinking, imagery, fantasy, memory and perceptual disorders. Differentiation From Re-experiences and Dissociative Phenomena Pseudohallucinations cannot be clearly discriminated from re-experiences, although the latter are always based on actual prior events (Table 3). Re-experiences are dened as recurrent memories that can consist of perceptions, hallucinations, imagination, thoughts, dreams, or ashbacks. Reexperiences not only occur in PTSD patients, but also as a posttraumatic symptom in dissociative disorders.29 A trauma can be so overwhelming that
Table 3. Characteristics of Re-experiences
Variable Re-experiences

Auditive Visual Haptic Olfactory Gustatory Internal localization External localization Vividness Reality testing Continuity over time Functional results Control Secondary delusions Trauma Cue-triggering

Yes Yes Yes Yes Yes Yes No Lifelike to faint/distorted Intact Often Anxiety-provoking No Possibility Yes Yes

normal information processing has been affected. Memories of the trauma are stored implicitly as sensory fragments only. Most of the time the trauma will be remembered as ashback experiences, or as visual, olfactory, auditory, or affective imprints.33 Activation (triggering) of these dissociated memories results in perceptions and images that receive virtually no elaboration from memory, and are of a non-past and non-self nature.34 Re-experiences can be seen as vivid sensory experiences related to anxiety-inducing past events, with unclear insight. With decreasing external stimuli demands (e.g., during relaxation, retirement) re-experiences tend to increase. In spite of their vivacity, re-experiences are not reliable memories. In fact, re-experiences have more in common with lifelike memories than with hallucinations. Horowitz35 proposed an extensive spectrum of re-experiencing that ranges from faint impressions to vivid, detailed, intrusive, repetitive memories and pseudohallucinations to hallucinations. Important dimensions of this spectrum are the degree of vividness and reality testing. Pseudohallucinations cannot be differentiated from perceptual distortions occurring in dissociative pathology (Table 4). Various US studies on dissociative disorders show that those disorders are often accompanied with hallucinations in all sensory modalities, especially in dissociative identity disorder (DID).36 One third to three fourths of patients with DID experience hallucinations, many have been previously diagnosed with schizophrenia. These hallucinations are often auditory and mainly experienced as internalized, usually coming from within the head and heard as distinctive voices with its own age, gender and personal attributes, e.g., imperative voices, or voices arguing with each other about the patients behavior. In some instances, the voices may be supportive or soothing. Typically, those voices start in early childhood and remain present in later life; they are never absent for a prolonged time. These experiences should not be considered as an isolated symptom; they are always associated with a cluster of dissociative symptoms, e.g., amnestic episodes, depersonalization, identity fragmentation, and a high degree of hypnotizability. Visual hallucinations are often nocturnal and less frequent. Those auditory and visual experiences seem to have low sensory vividness and are typically related to the

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Table 4. Characteristics of Dissociation

Variable Dissociation

Auditive Visual Internal localization External localization Vividness Reality testing Continuity over time Functional results Control Cue-triggering Other

Yes Yes Often Sometimes Lifelike to faint Intact Yes Anxiety-provoking/ supportive Seldom Sometimes Often congruent with personal past or functioning; childhood start; part of other dissociative symptoms

patients functioning or to past trauma, and it is believed that they can also be a representation of an alternate personality.15,29,37 Although hardly evidence-based, the experiences seem to be consistent with the concept of pseudohallucinations and might be the same phenomenon that was formerly known as hysterical or dissociative psychosis. However, in our opinion, psychosis would be too strong a label, while imagery would not capture its severity. Borderline personality patients can experience short lapses of reality testing (e.g., hours). The auditory and visual hallucinations appear to be manifestations of the intense anxiety resulting from the patients inability to cope with their stresses, particularly in unstructured situations.38 The hallucinations in those states should be called transient hallucinations, which suit them better than pseudohallucinations or micropsychosis, as the experiences share all characteristics of hallucinations, including loss of insight. However, later studies39 did not conrm the view that patients with borderline personality disorder characteristically experience brief psychotic episodes only. Many patients had symptoms lasting weeks to months.
CONCLUSIONS AND RECOMMENDATIONS

In sum, it is evident that pseudohallucinations cannot be readily distinguished from hallucinations, imagery, re-experiencing, or dissociative ex-

periences. Both pseudohallucinations and hallucinations can have an as-if character, coexist with intact reality testing, be experienced internally and involuntarily, and can be explained psychologically. It remains unclear whether pseudohallucinations can be as vivid as hallucinations. Imagery shares most of the properties with the former concepts, but sensory vividness and continuity in time is typically absent. Re-experiences can be distinguished from pseudohallucinations by the presence of past, traumatic events, cue-triggering, and intact reality testing. Pseudohallucination (characterized by insight, involuntariness, and internal localization) seems to t best with visual and auditory experiences seen among patients with DID. Evidently, there are experiences with intact reality testing that fall between the broad classes of hallucination and imagery. For some of these experiences characterized by intact reality testing, it seems more appropriate to use the term nonpsychotic hallucinations than pseudohallucinations. Except for reality testing, these experiences can share all features with traditional hallucinations. The concept of nonpsychotic hallucinations has two advantages: it avoids the denomination of pseudohallucinations as unreal or less severe, and it breaks the automatic link between hallucinations and psychosis. We recommend to subdivide pseudohallucinations into the following categories: (1) nonpsychotic hallucinations: (a) isolated nonpsychotic hallucinations, (b) vivid internal imagery; (2) partial hallucinations; and (3) transient hallucinations. Nonpsychotic hallucinations would include isolated hallucinations as seen among normals during grief reactions,20 among normal functioning individuals with auditory hallucinations, or among patients suffering from sensory deprivation, e.g., in CBS.28 Experiences in dissociative pathology are likely continuous with vivid internal imagery along Jaspers lines. Fading hallucinations with increasing insight are better considered partial hallucinations. Short lapses of reality testing in patients with borderline personality pathology should be called transient hallucinations. It will be evident that not all experiences can be readily categorized. Classication may benet from specifying the following formal aspects of perception, re-experiencing, and imagination (Spitzer,17 modied): modality (i.e., visual, audi-

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tory, haptic, olfactory, gustatory), complexity (i.e., simple v complex/formed experiences), localization (i.e., external v internal), degree of sensory vividness (e.g., bright, lifelike, contextual, compelling), degree of reality testing, degree of voluntary control, modulation over time (continuity), connection with thought disorders ([secondary] delusions, obsessions), and connection with trauma and dissociation. Table 5 shows how these factors can help in discriminating (albeit somewhat articially) between the different forms of psychopathology. Since all factors can all be present or absent in varying degrees, it is impossible to make sharp distinctions between all experiences; in other words: discriminant validity of these psychopathological symptoms is low. Most likely, uid transitions exist, resulting in a continuum from hallucinations (a perceptual disorder) to pseudohallucinations (in its most extreme form a thought disorder) and dissociative memory (re-experiences) to normal processes of memory, thought and fantasy,4,35,39,40

which language cannot adequately articulate. The continuum might best be conceptualised as overlapping circles (similar to Venn diagram), rather than a single line. Presumably, various symptoms on this continuum can coexist. The continuum hypothesis still leaves many questions unanswered. It remains unclear why in some disorders experiences can shift on the continuum (hallucinations in schizophrenia can be localized both internally and externally, can be vivid or faint), while they seem xed in other syndromes (hallucinations in CBS are always localized externally, with varying degrees of vividness). And why is it that pseudohallucinations are mainly referred to vision and audition, but rarely (if ever) to the other sense modalities? Perhaps the continuum exists only at a descriptive level, but is not tenable at the neurobiological level. The implications of this continuum hypothesis for our neurobiological, etiological, syndromal, and therapeutic body of thought have not been investigated yet. For example, does vivid imagery predispose to hallucinations? Are there

Table 5. Factors in the Specication of Processes of Perception, Re-experiencing, and Imagery

Hallucinations* Nonpsychotic Hallucinations Obsessional Imagery Re-experiences Fantasy and Imagery

Auditive Visual Haptic Olfactory Gustatory Internal localization External localization Vividness Reality testing Continuity over time Functional results Control Secondary delusions Trauma Cue-triggering Other

Often Sometimes Rarely Rarely Rarely Sometimes Often From lifelike to as-if character Impaired Yes Often anxietyprovoking No Often

Yes Yes Yes Often Sometimes Lifelike to faint Intact Yes Anxiety-provoking/ supportive Seldom No

Yes Yes Yes No Lifelike Intact No Anxiety-provoking/ wish-fullling No/temporary Possibility

Yes Yes Yes Yes Yes Yes No Lifelike to faint/ distorted Intact Often Anxiety-provoking No Possibility Yes Yes Always related to trauma

Yes Yes Yes No No Yes No Low Intact No Supportive, wish-fullling Yes No

Sometimes Often bizarre, dreamlike

Sometimes Often congruent with personal past or functioning

Often sexual, perverse or aggressive

Also: daydreams

* Includes transient hallucinations. Phantom limb pain, for example. No evidence in literature. Includes isolated hallucinations and vivid internal imagery. With the exception of partial hallucinations.

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diseases with pathognomonic qualitative aspects of perception, imagery, or thinking? (How) do nonpsychotic hallucinations respond to neuroleptics?* Although there is an unfortunate lack of data, a polyvalent concept as pseudohallucinations should only be part of a mental status examination when it receives further specication. Otherwise, the concept cannot be adequately discriminated from other psychopathological notions, and has few, if any, evidence-based consequences for daily practice. To
* It is known from case reports that nonpsychotic hallucinations in dissociative disorders and in Charles Bonnet syndrome do not respond to neuroleptics.28,37

date, the concepts main contribution is to give clinicians the opportunity to doubt the realness of hallucinations that do not comfortably t our diagnostic categories.6 Nevertheless, the simple dichotomy hallucinations versus pseudohallucinations results in an unjustied simplication of reality, leaving too many shades of gray unnoticed.
ACKNOWLEDGMENT
The authors wish to thank Professor B.P.R. Gersons, M.D., Ph.D., and D.H. Linszen M.D., Ph.D. for their critical comments on earlier versions of this manuscript, and J.H. Kamphuis, Ph.D. for his editorial contribution.

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