Hallucinations

by Oliver Sacks

She woke her husband; he could smell nothing, but she could still smell the smoke strongly. “I was shocked,” she said, “by how strongly I could smell something that wasn’t there.”

  Others may be haunted by a single constant smell of such complexity that it seems to conglomerate almost all the bad smells in the world. Bonnie Blodgett, in her book Remembering Smell, describes the phantosmic world she was plunged into following a sinus infection and the use of a potent nasal spray. She was driving along a state highway when she first detected a “weird” smell. She checked her shoes at a gas station, found them clean, then wondered if there was something amiss with the heater fan in the car—a dead bird perhaps? The smell pursued her, waxing and waning in intensity but never absent. She explored a dozen possible external causes and was finally, reluctantly, forced to the realization that the smell was in her head—in a neurological, not a psychiatric, sense. She described the smell as resembling “shit, puke, burning flesh and rotten eggs. Not to mention smoke, chemicals, urine and mold. My brain had truly outdone itself.” (Hallucination of particularly vile smells is called cacosmia.)

  While humans can detect and identify perhaps ten thousand distinct smells, the number of possible smells is far greater, for there are more than five hundred different odorant receptor sites in the nasal mucosa, and stimulation of these (or their cerebral representations) may be combined in trillions of ways. Some hallucinated smells may be impossible to describe because they are different from anything ever experienced in the real world, and evoke no memories or associations. New, unprecedented experiences can be a hallmark of hallucinations, for when the brain is released from the constraints of reality, it can generate any sound, image, or smell in its repertoire, sometimes in complex and “impossible” combinations.

  1. Molly Birnbaum, an aspiring chef who became anosmic after being struck by a car, has described the anosmic’s predicament eloquently in her memoir Season to Taste.

  2. Among these other conditions is infection with the herpes simplex virus, which can attack nerves (including sometimes the olfactory nerves), both impairing and stimulating them. The virus can remain dormant for long periods, sequestered in nerve ganglia, and suddenly reemerge at intervals of months or years. One man, a microbiologist, wrote to me: “In the summer of 2006, I began to ‘smell things,’ a faint pervasive odor that I could not identify (my best guess was … wet cardboard).” Prior to this, he said, “I had a highly sensitive nose, and was able to identify my laboratory cultures by smell alone, or subtle differences in organic solvents, or faint perfumes.”

  He soon developed a constant hallucination of the smell of rotting fish, which faded only after a year had passed, along with most of his “olfactory acuity and the subtlety of most foods.” He wrote:

  Certain odors are completely gone—feces(!), baking bread, or cookies, roasting turkey, garbage, roses, the fresh soil smell of Streptomyces … all gone. I miss the smells of Thanksgiving, but not the smell of public toilets.

  The dysosmia and phantosmia were due to a reemergence of the herpes simplex 2 which he had contracted many years before, and he is intrigued that these are always preceded by hallucinatory smells. He writes, “I smell the onset of herpes reactivation. A day or two prior to the onset of a neuritis episode, I again have olfactory hallucinations of the last strong smell I noticed. [This smell] persists during the neuritis and fades as the neuritis fades.… The strength of the hallucinations is correlated with the severity of the generalized neuritis.”

  4

  Hearing Things

  In 1973 the journal Science published an article that caused an immediate furor. It was entitled “On Being Sane in Insane Places,” and it described how, as an experiment, eight “pseudopatients” with no history of mental illness presented themselves at a variety of hospitals across the United States. Their single complaint was that they “heard voices.” They told hospital staff that they could not really make out what the voices said but that they heard the words “empty,” “hollow,” and “thud.” Apart from this fabrication, they behaved normally and recounted their own (normal) past experiences and medical histories. Nonetheless, all of them were diagnosed as schizophrenic (except one, who was diagnosed with “manic-depressive psychosis”), hospitalized for up to two months, and prescribed antipsychotic medications (which they did not swallow). Once admitted to the mental wards, they continued to speak and behave normally; they reported to the medical staff that their hallucinated voices had disappeared and that they felt fine. They even kept notes on their experiment, quite openly (this was registered in the nursing notes for one pseudopatient as “writing behavior”), but none of the pseudopatients were identified as such by the staff.1 This experiment, designed by David Rosenhan, a Stanford psychologist (and himself a pseudopatient), emphasized, among other things, that the single symptom of “hearing voices” could suffice for an immediate, categorical diagnosis of schizophrenia even in the absence of any other symptoms or abnormalities of behavior. Psychiatry, and society in general, had been subverted by the almost axiomatic belief that “hearing voices” spelled madness and never occurred except in the context of severe mental disturbance.

  This belief is a fairly recent one, as the careful and humane reservations of early researchers on schizophrenia made clear. But by the 1970s, antipsychotic drugs and tranquilizers had begun to replace other treatments, and careful history taking, looking at the whole life of the patient, had largely been replaced by the use of DSM criteria to make snap diagnoses.

  Eugen Bleuler, who directed the huge Burghölzli asylum near Zurich from 1898 to 1927, paid close and sympathetic attention to the many hundreds of schizophrenic people under his care. He recognized that the “voices” his patients heard, however outlandish they might seem, were closely associated with their mental states and delusions. The voices, he wrote, embodied “all their strivings and fears … their entire transformed relationship to the external world … above all … [to] the pathological or hostile powers” that beset them. He described these in vivid detail in his great 1911 monograph, Dementia Praecox; or, The Group of Schizophrenias:

  The voices not only speak to the patient, but they pass electricity through the body, beat him, paralyse him, take his thoughts away. They are often hypostasized as people, or in other very bizarre ways. For example, a patient claims that a “voice” is perched above each of his ears. One voice is a little larger than the other but both are about the size of a walnut, and they consist of nothing but a large ugly mouth.

  Threats or curses form the main and most common content of the “voices.” Day and night they come from everywhere, from the walls, from above and below, from the cellar and the roof, from heaven and from hell, from near and far.… When the patient is eating, he hears a voice saying, “Each mouthful is stolen.” If he drops something, he hears, “If only your foot had been chopped off.”

  The voices are often very contradictory. At one time they may be against the patient … then they may contradict themselves.… The roles of pro and con are often taken over by voices of different people.… The voice of a daughter tells a patient: “He is going to be burned alive,” while his mother’s voice says, “He will not be burned.” Besides their persecutors the patients often hear the voice of some protector.

  The voices are often localized in the body.… A polyp may be the occasion for localizing the voices in the nose. An intestinal disturbance brings them into connection with the abdomen.… In cases of sexual complexes, the penis, the urine in the bladder, or the nose utter obscene words.… A really or imaginarily gravid patient will hear her child or children speaking inside her womb.…

  Inanimate objects may speak. The lemonade speaks, the patient’s name is heard to be coming from a glass of milk. The furniture speaks to him.

  Bleuler wrote, “Almost every schizophrenic who is hospitalized hears ‘voices.’ ” But he emphasized that the reverse did not hold—that hearing voices did not necessarily denote schizophrenia. In the popular imagina
tion, though, hallucinatory voices are almost synonymous with schizophrenia—a great misconception, for most people who do hear voices are not schizophrenic.

  Many people report hearing voices which are not particularly directed at them, as Nancy C. wrote:

  I hallucinate conversations on a regular basis, often as I am falling asleep at night. It seems to me that these conversations are real and are actually taking place between real people, at the very time I’m hearing them, but are occurring somewhere else. I hear couples arguing, all kinds of things. They are not voices I can identify, they are not people I know. I feel like I’m a radio, tuned into someone else’s world. (Though always an American-English-speaking world.) I can’t think of any way to regard these experiences except as hallucinations. I am never a participant; I am never addressed. I am just listening in.

  “Hallucinations in the sane” were well recognized in the nineteenth century, and with the rise of neurology, people sought to understand more clearly what caused them. In England in the 1880s, the Society for Psychical Research was founded to collect and investigate reports of apparitions or hallucinations, especially those of the bereaved, and many eminent scientists—physicists as well as physiologists and psychologists—joined the society (William James was active in the American branch). Telepathy, clairvoyance, communication with the dead, and the nature of a spirit world became the subjects of systematic investigation.

  These early researchers found that hallucinations were not uncommon in the general population. Their 1894 “International Census of Waking Hallucinations in the Sane” examined the occurrence and nature of hallucinations experienced by normal people in normal circumstances (they took care to exclude anyone with obvious medical or psychiatric problems). Seventeen thousand people were sent a single question:

  Have you ever, when believing yourself to be completely awake, had a vivid impression of seeing or being touched by a living being or inanimate object, or of hearing a voice, which impression, as far as you could discover, was not due to an external physical cause?

  More than 10 percent responded in the affirmative, and of those, more than a third heard voices. As John Watkins noted in his book Hearing Voices, hallucinated voices “having some kind of religious or supernatural content represented a small but significant minority of these reports.” Most of the hallucinations, however, were of a more quotidian character.

  Perhaps the commonest auditory hallucination is hearing one’s own name spoken—either by a familiar voice or an anonymous one. Freud, writing in The Psychopathology of Everyday Life, remarked on this:

  During the days when I was living alone in a foreign city—I was a young man at the time—I quite often heard my name suddenly called by an unmistakable and beloved voice; I then noted down the exact moment of the hallucination and made anxious enquiries of those at home about what had happened at that time. Nothing had happened.2

  The voices that are sometimes heard by people with schizophrenia tend to be accusing, threatening, jeering, or persecuting. By contrast, the voices hallucinated by the “normal” are often quite unremarkable, as Daniel Smith brings out in his book Muses, Madmen, and Prophets: Hearing Voices and the Borders of Sanity. Smith’s own father and grandfather heard such voices, and they had very different reactions. His father started hearing voices at the age of thirteen, Smith writes:

  These voices weren’t elaborate, and they weren’t disturbing in content. They issued simple commands. They instructed him, for instance, to move a glass from one side of the table to another or to use a particular subway turnstile. Yet in listening to them and obeying them his interior life became, by all reports, unendurable.

  Smith’s grandfather, by contrast, was nonchalant, even playful, in regard to his hallucinatory voices. He described how he tried to use them in betting at the racetrack. (“It didn’t work, my mind was clouded with voices telling me that this horse could win or maybe this one is ready to win.”) It was much more successful when he played cards with his friends. Neither the grandfather nor the father had strong supernatural inclinations; nor did they have any significant mental illness. They just heard unremarkable voices concerned with everyday things—as do millions of others.

  Smith’s father and grandfather rarely spoke of their voices. They listened to them in secrecy and silence, perhaps feeling that admitting to hearing voices would be seen as an indication of madness or at least serious psychiatric turmoil. Yet many recent studies confirm that it is not that uncommon to hear voices and that the majority of those who do are not schizophrenic; they are more like Smith’s father and grandfather.3

  It is clear that attitudes to hearing voices are critically important. One can be tortured by voices, as Daniel Smith’s father was, or accepting and easygoing, like his grandfather. Behind these personal attitudes are the attitudes of society, attitudes which have differed profoundly in different times and places.

  Hearing voices occurs in every culture and has often been accorded great importance—the gods of Greek myth often spoke to mortals, and the gods of the great monotheistic traditions, too. Voices have been significant in this regard, perhaps more so than visions, for voices, language, can convey an explicit message or command as images alone cannot.

  Until the eighteenth century, voices—like visions—were ascribed to supernatural agencies: gods or demons, angels or djinns. No doubt there was sometimes an overlap between such voices and those of psychosis or hysteria, but for the most part, voices were not regarded as pathological; if they stayed inconspicuous and private, they were simply accepted as part of human nature, part of the way it was with some people.

  Around the middle of the eighteenth century, a new secular philosophy started to gain ground with the philosophers and scientists of the Enlightenment, and hallucinatory visions and voices came to be seen as having a physiological basis in the overactivity of certain centers in the brain.

  But the romantic idea of “inspiration” still held, too—the artist, especially the writer, was seen or saw himself as the transcriber, the amanuensis, of a Voice, and sometimes had to wait years (as Rilke did) for the Voice to speak.4

  Talking to oneself is basic to human beings, for we are a linguistic species; the great Russian psychologist Lev Vygotsky thought that “inner speech” was a prerequisite of all voluntary activity. I talk to myself, as many of us do, for much of the day—admonishing myself (“You fool! Where did you leave your glasses?”), encouraging myself (“You can do it!”), complaining (“Why is that car in my lane?”), and, more rarely, congratulating myself (“It’s done!”). Those voices are not externalized; I would never mistake them for the voice of God, or anyone else.

  But when I was in danger once, trying to descend a mountain with a badly injured leg, I heard an inner voice that was wholly unlike my normal babble of inner speech. I had a great struggle crossing a stream with a buckled and dislocating knee. The effort left me stunned, motionless for a couple of minutes, and then a delicious languor came over me, and I thought to myself, Why not rest here? A nap maybe? This was immediately countered by a strong, clear, commanding voice, which said, “You can’t rest here—you can’t rest anywhere. You’ve got to go on. Find a pace you can keep up and go on steadily.” This good voice, this Life voice, braced and resolved me. I stopped trembling and did not falter again.

  Joe Simpson, climbing in the Andes, also had a catastrophic accident, falling off an ice ledge and ending up in a deep crevasse with a broken leg. He struggled to survive, as he recounted in Touching the Void—and a voice was crucial in encouraging and directing him:

  There was silence, and snow, and a clear sky empty of life, and me, sitting there, taking it all in, accepting what I must try to achieve. There were no dark forces acting against me. A voice in my head told me that this was true, cutting through the jumble in my mind with its coldly rational sound.

  It was as if there were two minds within me arguing the toss. The voice was clean and sharp and commanding. It was always right, an
d I listened to it when it spoke and acted on its decisions. The other mind rambled out a disconnected series of images, and memories and hopes, which I attended to in a daydream state as I set about obeying the orders of the voice. I had to get to the glacier.… The voice told me exactly how to go about it, and I obeyed while my other mind jumped abstractly from one idea to another.… The voice, and the watch, urged me into motion whenever the heat from the glacier halted me in a drowsy exhausted daze. It was three o’clock—only three and a half hours of daylight left. I kept moving but soon realized that I was making ponderously slow headway. It didn’t seem to concern me that I was moving like a snail. So long as I obeyed the voice, then I would be all right.

  Such voices may occur with anyone in situations of extreme threat or danger. Freud heard voices on two such occasions, as he mentioned in his book On Aphasia:

  I remember having twice been in danger of my life, and each time the awareness of the danger occurred to me quite suddenly. On both occasions I felt “this was the end,” and while otherwise my inner language proceeded with only indistinct sound images and slight lip movements, in these situations of danger I heard the words as if somebody was shouting them into my ear, and at the same time I saw them as if they were printed on a piece of paper floating in the air.

  The threat to life may also come from within, and although we cannot know how many attempts at suicide have been prevented by a voice, I suspect this is not uncommon. My friend Liz, following the collapse of a love affair, found herself heartbroken and despondent. About to swallow a handful of sleeping tablets and wash them down with a tumbler of whiskey, she was startled to hear a voice say, “No. You don’t want to do that,” and then “Remember that what you are feeling now you will not be feeling later.” The voice seemed to come from the outside; it was a man’s voice, though whose she did not know. She said, faintly, “Who said that?” There was no answer, but a “granular” figure (as she put it) materialized in the chair opposite her—a young man in eighteenth-century dress who glimmered for a few seconds and then disappeared. A feeling of immense relief and joy came over her. Although Liz knew that the voice must have come from the deepest part of herself, she speaks of it, playfully, as her “guardian angel.”