Hallucinations
Hallucinations are false sensory perceptions occurring without an external stimulus, experienced as real by the individual, and can involve any sensory modality including auditory, visual, tactile, olfactory, or gustatory.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Schizophrenia | AH (esp 3rd person / running commentary / thought echo) + delusions + negative symptoms + young adult onset + > 6 months | 「你幾時第一次聽到啲聲？有冇覺得人哋控制你嘅思想？」(Age of onset, first-rank Sx) |
| Substance-induced psychosis | Temporal relationship with substance use; resolves with abstinence | 「你最後一次飲酒/食嘢係幾時？停咗之後啲聲有冇少咗？」 | |
| Serious Not To Miss | Delirium (medical emergency) | Acute onset, fluctuating course, impaired attention, altered consciousness [8] | 「佢最近有冇突然搞唔清楚、時清時唔清？」(Ask informant); serial sevens test |
| Intracranial tumour | Focal neurological deficits, raised ICP signs, seizures; occipital tumours → VH [9] | 「有冇頭痛、嘔、手腳冇力？」+ fundoscopy for papilloedema | |
| Temporal lobe epilepsy | Episodic hallucinations (olfactory/gustatory/déjà vu) + automatisms + post-ictal confusion | 「有冇試過突然聞到燒焦味然後失咗神？」 | |
| Psychotic depression with suicidal risk | Mood-congruent 2nd person AH (critical, derogatory) + depressive features | 「啲聲係咪鬧你或者叫你去死？心情低唔低落？」 | |
| Pitfalls | Dementia with Lewy bodies (DLB) | Recurrent well-formed VH + cognitive fluctuations + parkinsonism (onset within 1 year) [6][7] | 「有冇見到啲人或者動物但其他人見唔到？行路有冇慢咗或者手震？」 |
| Charles Bonnet syndrome | VH in context of severe visual impairment; insight preserved; no other psychotic Sx | 「你睇嘢清唔清楚？你知唔知道你見到嘅嘢唔係真？」 | |
| Hypnagogic/hypnopompic hallucinations | Occur at sleep-wake transition; are NORMAL [4] | 「係就嚟瞓著定啱啱醒嗰陣先有？」 | |
| Masquerades | Drug side effects | Temporal relationship with drug initiation/dose change | 「最近有冇開始食新藥或者加咗藥量？」 |
| Metabolic: hypercalcaemia | 'Psychiatric overtones': confusion, depression, anxiety, hallucinations [10] | 「有冇骨痛、成日口渴、便秘？」 | |
| Hepatic encephalopathy | Chronic liver disease + confusion + flapping tremor | 「你有冇肝病？」+ check for flapping tremor | |
| Trying to Tell Me Something? | Psychosocial stress / fear of "going crazy" / family conflict / bereavement / work stress | Hidden agenda: may come because family noticed changes, or fear of diagnosis | 「你最擔心啲咩？點解揀今日嚟？屋企人對呢件事有咩反應？」 |
6-Minute Consultation Structure
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好，我係X醫生，今日想同你傾下你嘅情況，大概傾六分鐘左右，可以嗎？」 | Greeting + permission + signposting = interpersonal marks |
| 0:30–1:30 | Chief complaint & HPI – onset, type, modality, content, frequency, course | 「你今日嚟睇醫生，最主要想解決咩問題？」→「你幾時開始聽到/見到呢啲嘢？」→「係慢慢開始定突然嚟？」→「有幾經常？最近有冇嚴重咗？」 | Captures CC and HPI accurately; also uncovers hidden agenda ("Why today?") |
| 1:30–2:30 | Characterise the hallucination – modality (auditory/visual/others), 1st/2nd/3rd person, command, Schneider features; associated delusions, disorganised thinking | 「你聽到嘅聲音係講啲咩？」→「佢哋係同你講嘢定係講你？」→「有冇叫你去做啲嘢？」→「有冇見到啲人哋見唔到嘅嘢？」 | Differentiates schizophrenia vs organic vs mood disorder; detects risk (command hallucinations) |
| 2:30–3:30 | Red flags & systems review – substance use, medications, fever, head injury, confusion, seizures, mood, suicide risk, cognitive decline | 「你有冇飲酒、食藥或者用毒品？」→「最近有冇跌親撞親個頭？」→「有冇發燒或者成日好攰？」→「有冇諗過唔想活落去或者傷害自己？」 | Screens for organic causes (delirium, substances, epilepsy) and safety (suicide/violence risk) |
| 3:30–4:30 | PMHx, DHx, FHx, Social Hx – psychiatric Hx, chronic illness, medications (esp anticholinergics, steroids, dopamine agonists), family psych Hx, living situation, occupation, functional impact | 「你之前有冇睇過精神科？」→「食緊啲咩藥？」→「屋企有冇人有精神病？」→「你而家一個人住定同屋企人住？」→「呢啲嘢有冇影響你返工或者日常生活？」 | Completes biopsychosocial picture; medication causes are a classic trap |
| 4:30–5:15 | ICE – Ideas, Concerns, Expectations | 「你自己覺得呢啲聲音/影像係咩嚟㗎？」(Ideas)→「你最擔心啲咩？」(Concerns)→「你今日嚟最想我幫到你啲咩？」(Expectations) | Direct marks on CRF Q3 |
| 5:15–5:45 | Summarise & check understanding | 「我總結返：你由X月開始聽到…你最擔心…你想我哋幫你…我有冇講漏咗？」 | Shows active listening; empathy mark |
| 5:45–6:00 | Safety-net & close | 「如果啲聲音叫你傷害自己或者其他人，一定要即刻去急症室或者打999。我哋會安排你盡快去睇精神科。」→「多謝你信任我同我分享，有咩擔心隨時返嚟搵我哋。」 | Safe closure + urgent referral pathway |
Uncovering the hidden agenda: The symptom is hallucinations, but the real reason for coming today may be fear of "going crazy," family pressure, functional decline, command hallucinations causing fear, or concern about a relative with similar illness. Always ask: 「點解你揀今日嚟？」and explore ICE thoroughly.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset & course | When did it start? Sudden or gradual? Getting worse? | 「幾時開始？係突然定慢慢嚟？有冇越嚟越嚴重？」 | Acute → delirium/substance; insidious → schizophrenia/dementia | Acute: delirium, substance; Chronic: schizophrenia, DLB |
| Modality | Do you hear voices? See things? Smell/taste/feel things? | 「你聽到聲音？見到嘢？有冇聞到奇怪嘅味？皮膚有冇奇怪感覺？」 | Visual hallucinations likely indicate organic conditions [1]; AH most common in functional psychosis [2] | VH → organic (delirium, DLB, epilepsy, substance); AH → schizophrenia, mood disorder |
| Content & form (AH) | What do the voices say? 2nd or 3rd person? Running commentary? Command? | 「啲聲講啲咩？係直接同你講嘢定講你？有冇叫你做嘢？」 | 3rd person AH, running commentary, thought echo = Schneider first-rank symptoms [3] | Schizophrenia |
| Insight | Do you believe the voices/visions are real? | 「你覺得呢啲聲音/影像係真㗎定你覺得唔係真？」 | Preserved insight → pseudohallucination, grief, Charles Bonnet; poor insight → psychosis | Pseudohallucination vs true hallucination |
| Context / alertness | Are you fully awake when it happens? Just falling asleep/waking up? | 「你聽到/見到嗰陣時係完全清醒㗎嘛？定係就嚟瞓著或者啱啱醒？」 | Hypnagogic/hypnopompic hallucinations are NORMAL [4] | Normal physiological phenomenon |
| Associated psychotic Sx | Any strange beliefs? People trying to harm you? Thoughts being controlled? | 「有冇覺得有人想害你？有冇覺得人哋可以控制你嘅思想？」 | Delusions + hallucinations → psychotic disorder | Schizophrenia, delusional disorder, psychotic depression |
| Mood Sx | Feeling low? Lost interest? Feeling very high/energetic? | 「心情有冇好低落？有冇對嘢冇晒興趣？或者有冇覺得好興奮、好多精力？」 | Mood-congruent hallucinations occur in depression and mania [3] | Psychotic depression, mania |
| Substance use | Alcohol, drugs (cannabis, meth, ketamine, LSD)? How much? Recent withdrawal? | 「你有冇飲酒？食大麻、冰毒、K仔？最近有冇突然停咗？」 | Formication a/w cocaine and alcohol withdrawal [3]; substance-induced psychosis very common in HK | Substance-induced psychosis, delirium tremens, alcoholic hallucinosis |
| Medications | Current medications? Any recent changes or new drugs? | 「你而家食緊咩藥？有冇啱啱轉過藥或者食新藥？」 | Anticholinergics, dopamine agonists, steroids, oseltamivir (neuropsychiatric effects incl hallucinations) [5] can cause hallucinations | Drug-induced hallucinations |
| Cognitive decline | Memory problems? Getting lost? Day-to-day fluctuation? | 「記性差咗？有冇試過唔記得路？有冇時好時差？」 | DLB: cognitive fluctuations + well-formed VH + parkinsonism [6][7] | Dementia with Lewy bodies |
| Seizure Hx | Funny smells before? Blackouts? Tongue biting? | 「有冇試過突然聞到燒焦味？有冇暈過去？有冇咬親脷？」 | TLE: classic olfactory hallucination (rubber burning smell) [1] | Temporal lobe epilepsy |
| Red flags – delirium | Acute confusion? Fluctuating consciousness? Fever? Recent surgery/illness? | 「最近有冇突然搞唔清楚？有冇發燒或者啱啱做過手術？」 | Delirium: hallucinations (esp VH) + impaired attention + acute fluctuating course [8] | Delirium (medical emergency) |
| Suicide & violence risk | Thoughts of self-harm? Harming others? Acting on commands? | 「有冇諗過傷害自己或者其他人？有冇跟住啲聲音做嘢？」 | Command hallucinations = high risk; must assess and document | Urgent psychiatric referral |
| FHx | Family history of mental illness? | 「屋企有冇人有精神病？」 | Strong genetic component in schizophrenia | Schizophrenia |
| Social / functional | Impact on work, relationships, self-care? Who do you live with? | 「呢啲嘢有冇影響到你返工、同人相處或者自己照顧自己？」 | Functional impairment = severity marker; social isolation is both risk factor and consequence | Biopsychosocial assessment |
| Bereavement | Recent loss of a loved one? | 「最近有冇親人過咗身？」 | Bereavement (grief reaction) can cause pseudohallucinations [1] | Normal grief reaction |
| Sensory deprivation | Any hearing loss or visual impairment? | 「你聽嘢或者睇嘢有冇差咗？」 | Hallucinations can occur after sensory deprivation (blindness → Charles Bonnet; deafness → musical hallucinations) [1] | Charles Bonnet syndrome, musical hallucinations |
Case Report Form Answer Builder
- CC: "Hearing voices / seeing things that others cannot" – state modality, duration
- HPI high-yield points: onset (acute vs insidious), modality (AH/VH/others), content (2nd vs 3rd person, command), frequency, progression, associated features (delusions, mood Sx, cognitive decline, substance use, medication changes, physical illness), impact on function, alertness during episodes
Examples:
- "Patient's family noticed patient talking to himself and acting strangely – brought for assessment"
- "Patient distressed by persistent voices commanding self-harm"
- "Patient worried about 'going crazy'"
- Pick the single most important reason from ICE – usually the trigger for today's visit
| Example Wording | |
|---|---|
| Ideas | "Patient thinks the voices are spirits / side effect of medication / sign of brain disease" |
| Concerns | "Worried about going crazy / having a brain tumour / losing job / being institutionalised" |
| Expectations | "Wants the voices to stop / wants medication / wants reassurance that it is not cancer / wants referral to psychiatrist" |
- In a young adult (18–35) with > 1 month of AH (esp 3rd person / running commentary) + delusions + decline in function → Schizophrenia (if > 6 months) or Schizophreniform disorder (1–6 months)
- In an elderly patient with well-formed VH + cognitive fluctuation + parkinsonism → Dementia with Lewy bodies
- In a patient with acute onset, fluctuating consciousness, VH, medical illness → Delirium
- In a patient with clear temporal link to substance use → Substance-induced psychotic disorder
- Minimum supporting evidence: modality of hallucination, associated Sx, timeline, functional impact
| DDx | Key Discriminator |
|---|---|
| Substance-induced psychotic disorder | Hallucinations temporally related to substance use/withdrawal; resolve with abstinence |
| Delirium | Acute, fluctuating, impaired attention/consciousness, identifiable precipitant |
| Psychotic depression / Bipolar with psychotic features | Mood-congruent hallucinations + prominent mood syndrome |
(Adjust differentials based on the patient's age and presentation — e.g., for elderly: DLB, delirium, medication side effects)
| Domain | Example |
|---|---|
| Biological | Active psychotic symptoms (hallucinations ± delusions) requiring psychiatric assessment and likely pharmacotherapy |
| Psychological | Fear, distress, poor insight, risk of self-harm/harm to others (especially if command hallucinations present) |
| Social | Functional impairment (unable to work/study), social isolation, family burden/carer stress, potential stigma |
| Diagnosis / DDx | Best Supporting Physical Sign | How to Elicit It | Why It Supports This Diagnosis |
|---|---|---|---|
| Schizophrenia | No reliable single physical sign in brief FM station | Observe for disorganised behaviour, responding to unseen stimuli, blunted affect, thought disorder during interview | Behavioural observation during MSE supports psychosis; formal diagnosis relies on psychiatric history |
| Delirium | Impaired attention (inattention is hallmark) [8] | Serial sevens or "spell WORLD backwards"; note distractibility during interview | Inattention differentiates delirium from primary psychosis |
| DLB | Parkinsonism (rigidity, bradykinesia, resting tremor) [6] | Assess tone (cogwheel rigidity), observe gait (shuffling, reduced arm swing), check for resting tremor | Parkinsonism within 1 year of cognitive decline + VH = DLB |
| Substance withdrawal (alcohol) | Tremor, sweating, tachycardia | Outstretched hands for tremor; vital signs | Autonomic hyperactivity in withdrawal states |
| Hepatic encephalopathy | Flapping tremor (asterixis) – present in ≥ Grade 2 HE [11] | Ask patient to dorsiflex wrists with arms outstretched, hold for 15 seconds | Asterixis = involuntary loss of muscle tone, highly suggestive of metabolic encephalopathy |
| Intracranial tumour | Papilloedema | Fundoscopy | Raised ICP suggests space-occupying lesion |
| Temporal lobe epilepsy | No reliable sign between episodes | EEG is the investigation; may find focal neurological signs if structural lesion | Diagnosis relies on Hx + EEG |
Exam Discriminators and Traps
Top Traps That Lose Marks
- Assuming all hallucinations = schizophrenia. Always rule out organic causes first — visual hallucinations likely indicate organic conditions [1].
- Forgetting to ask about substance use. Substance-induced psychosis is extremely common and a favourite exam trap.
- Not assessing suicide/violence risk when command hallucinations are present — this is a must-document safety issue.
- Missing delirium in an elderly patient. Acute VH + fluctuating attention + medical illness = delirium until proven otherwise.
- Confusing DLB with delirium — both have fluctuating cognition and VH, but DLB is chronic with parkinsonism [7].
- Forgetting hypnagogic/hypnopompic hallucinations are NORMAL [4] — don't pathologise sleep-transition experiences.
- Not asking about sensory deprivation (Charles Bonnet syndrome in visual loss, musical hallucinations in deafness) [1].
- Not eliciting ICE — direct marks lost on the CRF.
| Red Flag | Action |
|---|---|
| Command hallucinations to harm self/others | Urgent psychiatric referral / A&E |
| Active suicidal ideation or plan | Urgent psychiatric referral / A&E |
| Features of delirium (acute confusion, altered consciousness) | Admit medically; find and treat cause |
| Focal neurological deficits + hallucinations | Urgent CT/MRI brain to exclude tumour/stroke |
| First episode psychosis | Urgent psychiatry referral (early intervention service) |
| Hallucinations + fever + neck stiffness | Exclude meningitis/encephalitis — A&E |
「如果啲聲音叫你傷害自己或者其他人，你一定要即刻去急症室或者打999。我會幫你安排盡快睇精神科專科。你有冇信任嘅人可以陪你？」
High Yield Summary
What to ASK: Modality (AH vs VH vs others) → Content (2nd/3rd person, command) → Onset/course → Substance use → Medications → Cognitive decline → Mood → Red flags (suicide, delirium, focal neuro) → ICE → Functional impact.
What to WRITE on CRF: State modality + duration + key associated features in CC/HPI. One clear reason for consultation. ICE verbatim. Most likely Dx with minimum 2–3 supporting features. Three DDx with discriminators. Biopsychosocial problems. Physical sign (or MSE finding if schizophrenia).
What NOT to MISS: (1) Organic causes — VH = organic until proven otherwise. (2) Command hallucinations → suicide/violence risk. (3) Delirium in elderly. (4) Substance use. (5) DLB in elderly with VH + parkinsonism + cognitive fluctuation. (6) Don't pathologise hypnagogic/hypnopompic hallucinations.
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: Seminar 2 - Psychopathology - Dr Simon SY Lui_1_9_2025.pdf (Hallucinations slide) [2] Lecture slides: Seminar 1 - Psychiatric History Taking and Mental State Examination - Dr SE Chua_20250825.pdf (Perception section) [3] Senior notes: Ryan Ho Psychiatry.pdf (p15, p32 – Auditory Hallucinations, MSE Perception) [4] Lecture slides: Seminar 1 - Psychiatric History Taking and Mental State Examination - Dr SE Chua_20250825.pdf (Perception – hypnagogic/hypnopompic) [5] Senior notes: MBBS Final MB (Pediatrics) (Felix PY Lai).pdf (p104 – Oseltamivir neuropsychiatric effects) [6] Senior notes: Maksim Medicine Notes.pdf (p253 – Dementia with Lewy bodies) [7] Lecture slides: GC 241. Reference (3) - Patel dementia with lewy bodies.pdf (p5 – DLB diagnostic tools and psychosis) [8] Senior notes: Ryan Ho Fundamentals.pdf (p325 – Delirium) / Ryan Ho Neurology.pdf (p95 – Delirium) [9] Senior notes: Maksim Surgery Notes.pdf (p362 – Occipital lobe tumours → VH) [10] Senior notes: Ryan Ho Chemical Path.pdf (p22 – Hypercalcaemia psychiatric overtones) / Ryan Ho Respiratory.pdf (p143) [11] Senior notes: Block A - A jaundiced and incoherent patient_ liver failure.pdf (p16 – Flapping tremor ≥ Grade 2 HE)
Halitosis
Halitosis is an unpleasant oral malodor most commonly caused by bacterial degradation of sulfur-containing substrates in the oral cavity, particularly on the tongue dorsum and in periodontal pockets.
Hand Pain
Hand pain is a symptom arising from injury, overuse, or disease affecting the bones, joints, tendons, nerves, or soft tissues of the hand, commonly caused by conditions such as carpal tunnel syndrome, osteoarthritis, tendinitis, or trauma.