Madness Explained

by Richard P. Bental

  It was the second patient who helped me to overcome my now growing therapeutic pessimism. Speaking to Brian1 for the first time as we sat together in a small side room, it suddenly occurred to me that, during my lengthy training, no one had thought it necessary to instruct me in the best way of talking to mad people. I was not sure where to start. I need not have worried. Brian was charming and helpful. No doubt assisted by the many previous occasions on which he had told his story, he described how his problems had developed after he had failed at college, the years of periodic hospital treatment that had followed, and the violent confrontation with his father that had led to his recent admission. With hardly a pause for breath, he then proceeded to talk about his voices. He told me that they appeared to originate from inside his head, but seemed as real to him as my voice. They revealed to him evidence of a Jewish plot to confine Gentiles to concentration camps and, at the same time, tormented him with the simple refrain, ‘Give cancer to the crippled bastard!’

  Brian believed that the voices were being projected into his head by a team of parapsychologists, and asked me to use whatever influence I might have to end this bizarre and, to his mind, unethical experiment. Yet, even on the occasion of our first meeting, it was obvious that his voices were not merely the random product of a damaged nervous system. The ‘crippled bastard’ referred to by the voices was easily identifiable – Brian was sitting in a wheelchair, having crushed his legs in a bungled suicide attempt. (He had jumped from the top floor of a multistorey car park.) I later learned that the girlfriend who had recently abandoned him was Jewish. I also learned that Brian’s mother had died from cancer. No doubt ‘Give cancer to the crippled bastard!’ encapsulated a constellation of ideas linked by a common thread of guilt.

  Emboldened by this insight, I tried to help Brian gain some understanding of his experiences. Over the following few months, we met regularly for periods of half an hour or so (any longer and he became exhausted). Sometimes I would sit in silence as Brian listened to his voices and described what they were saying, so that we could consider how their content might relate to events that had befallen him. At other times we considered the idea that his voices might be fragments of his mind that had somehow become separated from his conscious self. As the weeks passed, the voices became less frequent, and Brian’s belief that he was the victim of a parapsychological experiment diminished. In retrospect, I realize that my efforts were not particularly well thought-out and, of course, it is possible (as a particularly cynical nurse enjoyed pointing out to me) that much of the improvement Brian experienced was due to simultaneous adjustments to his medication. However, Brian – a very gentle person who was happiest when idly strumming his guitar – seemed to gain something positive from our time together. Perhaps it was just the chance to have somebody listen to his point of view.

  Impossible Perceptions

  According to the historian German Berrios, ‘Experiences redolent of hallucinations and illusions are part of the common baggage of humanity.’2 Certainly, it is not difficult to find evidence of quasi-hallucinatory experiences in the historical record. As we saw earlier, American psychologist Julian Jaynes has attempted to account for the linguistic peculiarities of the Iliad by supposing that, in Ancient Greece, hallucinating was the normal mode of thinking.3 Although this bold hypothesis has been disputed,4 it is certainly true that hallucinatory experiences have been recorded since biblical times.5 Socrates, to take one well-documented example, had a ‘daemon’ that spoke to him, offering moral and political advice. Unfortunately, researchers have been slow to consider the relationship between hallucinations and normal perceptual processes. As psychologists Theodore Sarbin and Joseph Juhasz have noted, ‘Since the 1920s textbooks of general psychology have differentiated hallucinations from errors of perception by the simple expedient of locating them in separate chapters.’6

  Before the efforts of the classificationists of the nineteenth century, hallucinations were considered to be independent diseases rather than symptoms of more general conditions. A French psychiatrist, Jean-Etienne Esquirol, first offered a definition of hallucinations in a paper published in 1832, observing that the hallucinating person, ‘ascribes a body and actuality to images that the memory recalls without the intervention of the senses’.7 In this way, he distinguished between hallucinations (roughly perceptions of objects not present at the time) and illusions (the misperception of objects which are present).

  Modern definitions of hallucination are similar to Esquirol’s. For example, DSM-IV states that a hallucination is ‘A sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of the relevant sensory organ.’8 In an earlier book, Peter Slade and I attempted to be more precise by suggesting that a hallucination is ‘any percept-like experience which (a) occurs in the absence of an appropriate stimulus, (b) has the full force or impact of the corresponding actual (real) perception, and (c) is not amenable to the direct or voluntary control of the experiencer’.9 Our emphasis on the absence of an appropriate stimulus acknowledges that the world external to the individual does impact on hallucinations, as we will see later. However, even this definition is not without its difficulties. What are we to make, for example, of rare individuals who say that they can make themselves hallucinate?

  Karl Jaspers suggested that an important distinction could be made between ‘true’ hallucinations, which appear to be external to the individual (for example, a voice coming from somewhere beyond the boundaries of the body), and ‘pseudohallucinations’, such as those experienced by Brian, which are experienced as originating from inside the head.10 However, the usefulness of this distinction has been disputed, and most modern psychologists and psychiatrists lump both types of experience together. In my own clinical work, I have often found that patients describe their hallucinations as external to themselves but, after being encouraged to think about them carefully, decide that they are occurring inside them. Oddly, this reattribution does not seem to alter the perception that these experiences are caused by some kind of external agency.

  A phenomenon that appears to be a further step away from full blown hallucinations is known as thought insertion. Patients who have this experience say that they have thoughts inside their heads that have been put there by someone else. For example:

  I look out the window and I think that the garden looks nice and the grass looks cool, but the thoughts of Eamonn Andrews [a television presenter who was popular in Britain in the 1960s and 1970s] come into my mind… He treats my mind like a screen and flashes thoughts onto it like you flash a picture.11

  Intrusive or obsessional thoughts seem to lie still further down the scale of alienness. These kinds of thoughts, which are often the main complaint of non-psychotic patients given the diagnosis of obsessive-compulsive disorder, arrive unbidden in the head, and may vary from trivial memories (for example, an irritating advertising jingle that seems impossible to expel from the mind), to fears about violating social norms (for example, the worry that one might shout something out during a solemn ceremony, such as a marriage), to the self-critical automatic thoughts of the depressed patient. Surveys have established that just about everyone has these kinds of experiences, but that obsessional patients are unique in their fear of the consequences that might ensue (they may fear acting on thoughts that are socially unacceptable, for example,), and the efforts they make to suppress them.12

  The most common type of hallucination encountered in the modern psychiatric clinic is auditory and consists of voices, like Brian’s. As we have seen, these types of experiences, for example of voices telling the patient what to do or discussing the patient’s behaviour, were thought by Schneider to be first-rank symptoms of schizophrenia.13 Although some studies have shown that about three quarters of schizophrenia patients experience voices,14 this no doubt reflects modern psychiatrists’ adherence to Schneiderian diagnostic principles. Even so, hallucinations are often reported by patients receiv
ing other diagnoses, particularly bipolar disorder and, more recently, dissociative disorder,* leading some researchers to lament that they have no diagnostic specificity whatsoever.15

  Often, the voices described by patients have a negative quality. They may insult the patient, or tell the patient to do something unacceptable (for example, to commit suicide). However, it would be wrong to assume that this is invariably the case. When three American psychiatrists, Laura Miller, Eileen O’Connor and Tony DiPasquale, interviewed a group of chronically hallucinating patients they found that many thought their voices were pleasant and they did not want them to disappear as a consequence of treatment. Some regarded their voices as important personages in their impoverished social networks, perhaps filling a gap created by the isolation they experienced as a consequence of their illness.16

  Hallucinations may also be experienced in other modalities, such as visual hallucinations of people who are not really present. I have met a number of patients who have claimed to see the Devil. (As we saw in Chapter6, these kinds of hallucinations are more often reported by patients in the developing world than by patients in the West.)17 Others may have tactile hallucinations in which they believe that invisible people are touching them, or olfactory hallucinations in which they experience unusual smells that are not detectable by others.

  Sometimes it is difficult to decide whether an experience really is a hallucination. For example, the term ‘olfactory reference syndrome’ has been used to describe a relatively circumscribed complaint in which the patient believes that he smells.18 In practice, it can be difficult to decide whether this belief reflects a delusional explanation of social isolation (‘People are avoiding me, and it’s probably because I smell’) or an olfactory hallucination. It may also be difficult to distinguish between a hallucination and ordinary mental imagery. I once saw a patient in a high-security hospital who complained of visual hallucinations in which he would ‘see’ himself having sex with naked women. When I suggested that it was not unusual for bored and sexually deprived young men to have these kinds of experiences, he insisted that his visions could not be mere fantasies, because the women were unknown to him and, ‘You can’t imagine someone you’ve never met in real life.’

  The idea that hallucinations exist on a continuum with normal mental imagery was suggested by American psychiatrist John Strauss in an influential paper published in 1969.19 Strauss studied schizophrenia patients’ accounts of their positive symptoms and concluded that they could be classified along four dimensions: the strength of the individual’s conviction in the objective reality of the experience; the extent to which the experience seems to be independent of stimuli or cultural determinants; the individual’s preoccupation with the experience; and its implausibility. ‘Full-blown’ hallucinations fall at the end of all of these dimensions. However, there is no doubt that some experiences fall midway along these dimensions (for example, you may think but not be certain that you have glimpsed someone you are hoping to avoid).

  Back to the illness debate

  In Chapter 5 we considered the possibility that there is a dimension of personality reflecting the extent to which people are likely to suffer from a psychotic illness.* On examining this evidence, we established that it is not necessary to assume that everyone who experiences a hallucination is suffering from an illness. Indeed, it was apparent that as many as ten times more people experience voices than receive treatment for psychosis. In Holland, Marius Romme and Sondra Escher have taken this discovery to its logical conclusion by forming a national society for people who hear voices.20

  Nevertheless, it is clear that hallucinations can be provoked by disturbances of the nervous system. They are common consequences of many medical conditions, including progressive sensory loss (blindness or deafness), fever, focal brain lesions, delirium and, most obviously, intoxication.21 Although a variety of drugs (including alcohol if consumed in sufficient quantities) can cause hallucinations, the most potent known hallucinogen is lysergic acid diethylamide (LSD), first synthesized in 1938 by the Swiss chemist Albert Hoffman. As we saw in Chapter 7, the discovery of LSD provoked the hypothesis that schizophrenia might be caused by an endogenous neurotoxin. One problem for this theory is that drug-induced hallucinations are usually quite different from those reported by patients in the absence of intoxication. For example, the hallucinations induced by LSD and other drugs usually consist of intense visual experiences involving bright colours, and explosive, concentric, rotational or pulsating movements like those originally described by Hoffman.22

  Careful medical investigations have revealed that only a very small proportion of psychiatric patients who experience hallucinations suffer from a recognizable medical condition. In a study by Eve Johnstone, Fiona MacMillan and Tim Crow at Northwick Park Hospital, near London, 15 out of 268 patients with an initial diagnosis of schizophrenia were found to be suffering from an identifiable medical disorder and, of these, 10 were experiencing hallucinations.23 In a similar study in the United States, it was found that hallucinations associated with medical illness generally appear suddenly, and are usually visual.24

  Learning to live with voices

  When Marius Romme compared voice-hearers who had been diagnosed as suffering from a mental illness with others who had not, he found remarkably few differences in the experiences of the two groups. Both patients and non-patients experienced a combination of positive and negative voices, but the proportion of positive voices was greater in the non-patients. The non-patients in contrast with the patients often felt they had some control over their voices.25 In Britain, a similar comparison conducted by Ivan Leudar and Phil Thomas found comparable results.26 The majority in both groups reported that their voices played a role in regulating everyday activities, for example by issuing instructions. For many of those interviewed, their voices appeared to be aligned with significant members of the person’s family, although this was less so for the patients. Overall, these similarities suggest that it is not hallucinations per se that determine whether people seek help from psychiatric services, but how well they are able to cope with these experiences.

  Marius Romme and Sondra Escher have suggested that the process of adapting to hallucinations occurs in three distinct stages. They found that the majority of those they interviewed first heard voices during a period of emotional turmoil or following a traumatic experience of some kind. When the voices appeared, they typically provoked feelings of confusion, panic and powerlessness. However, this was usually followed by a phase, lasting months or even years, during which the person hearing voices struggled to find ways of coping. Some people learned to ignore their voices, others learned to listen to those that offered positive advice, and still others formulated some kind of ‘contract’ with the voices (for example, agreeing to listen to them for only a limited amount of time each day), which would limit their emotional impact. Eventually, some voice-hearers began to regard their voices as a positive facet of themselves.

  Romme and Escher’s observations have been echoed by recent studies carried out by clinical psychologists in Britain. Studies conducted by Paul Chadwick and Max Birchwood in Birmingham have shown that patients who believe that their voices are omniscient (all-seeing) and omnipotent (all-powerful) have greatest difficulty in coping with them, and that patients who appraise their voices as malevolent tend to resist them, whereas those who appraise their voices as benevolent tend to engage with them, by talking with them or taking seriously what they have to say.27 Extending this work further, Birchwood has recently studied the origins of these kinds of appraisals, finding that patients who believe themselves to be less powerful and lower in social rank than most other people are especially likely to regard themselves as subordinate to their voices.28 Patients’ relationships with their voices, it seems, mirror their relationships with other people.

  A slightly different approach to understanding patients’ appraisals of their hallucinations has been taken by my colleague in Manchester, Tony Morri
son, who has suggested that patients’ interpretations of their voices might be influenced by their more general beliefs about the mind.29 These kinds of metacognitive beliefs (literally, beliefs about beliefs) are known to play a role in obsessional thinking. For example, people who complain about intrusive thoughts often have excessive expectations of their mental efficiency, catastrophic fears about losing control of their thoughts, and superstitious beliefs about the consequences of this happening (for example, ‘If I did not control a worrying thought, and then what I worried about really happened, it would be my fault’). In a recent study, he has compared patients who hear voices with patients suffering from persecutory delusions, patients suffering from panic attacks, and ordinary people, finding that the hallucinating group had more dysfunctional metacognitive beliefs than any of the other groups.30

  Hear One Moment and Not the Next

  Most people who hear voices do not hear them continuously or, if they do, the loudness and content of the voices vary. Research that has explored factors influencing these changes has provided important clues about the psychological mechanisms involved in experiencing hallucinations. Three factors appear to be particularly important.