Hallucinations

by Oliver Sacks

  Much deeper trauma and consequent PTSD (post-traumatic stress disorder) may affect anyone who has lived through a violent crash, a natural cataclysm, war, rape, abuse, torture, or abandonment—any experience that produces a terrifying fear for one’s own safety or that of others.

  All of these situations can produce immediate reactions, but there may also be, sometimes years later, post-traumatic syndromes of a malignant and often persistent sort. It is characteristic of these syndromes that, in addition to anxiety, heightened startle reactions, depression, and autonomic disorders, there is a strong tendency to obsessive rumination on the horrors which were experienced—and, not infrequently, sudden flashbacks in which the original trauma may be reexperienced in its totality with every sensory modality and with every emotion that was felt at the time.4 These flashbacks, though often spontaneous, are especially liable to be evoked by objects, sounds, or smells associated with the original trauma.

  The term “flashback” may not do justice to the profound and sometimes dangerous delusional states that can go with post-traumatic hallucinations. In such states, all sense of the present may be lost or misinterpreted in terms of hallucination and delusion. Thus the traumatized veteran, during a flashback, may be convinced that people in a supermarket are enemy soldiers and—if he is armed—open fire on them. This extreme state of consciousness is rare but potentially deadly.

  One woman wrote to me that, having been molested as a three-year-old and assaulted at the age of nineteen, “for both events smell will bring back strong flashbacks.” She continued:

  I had my first flashback of being assaulted as a child when a man sat next to me on a bus. Once I smelled [his] sweat and body odor, I was not on that bus anymore. I was in my neighbor’s garage and I remembered everything. The bus driver had to ask me to get off the bus when we arrived at our destination. I lost all sense of time and place.

  Particularly severe and long-lasting stress reactions may occur after rape or sexual assault. In a case reported by Terry Heins and his colleagues, for example, a fifty-five-year-old woman who had been forced to watch her parents’ sexual intercourse as a young child and then forced to have intercourse with her father at the age of eight experienced repeated flashbacks of the trauma as an adult, as well as “voices”—a post-traumatic stress syndrome that was misdiagnosed as schizophrenia and led to psychiatric hospitalization.

  People with PTSD are also prone to recurrent dreams or nightmares, often incorporating literal or somewhat disguised repetitions of the traumatic experiences. Paul Chodoff, a psychiatrist writing in 1963 about the effects of trauma in concentration camp survivors, saw such dreams as a hallmark of the syndrome and noted that in a surprising number of cases, they were still occurring a decade and a half after the war.5 The same is true of flashbacks.

  Chodoff observed that obsessive rumination on concentration camp experiences might diminish in some people with the passage of time, but others

  communicated an uncanny feeling that nothing of real significance had happened in their lives since their liberation, as they reported their experiences with a vivid immediacy and wealth of detail which almost made the walls of my office disappear, to be replaced by the bleak vistas of Auschwitz or Buchenwald.

  Ruth Jaffe, in a 1968 article, described one concentration camp survivor who had frequent attacks in which she relived her experience at the gates of Auschwitz, where she saw her sister led off into a group destined for death but could do nothing to save her, even though she tried to sacrifice herself instead. In her attacks, she saw people entering the gates of the camp and heard her sister’s voice calling, “Katy, where are you? Why do you leave me?” Other survivors are haunted by olfactory flashbacks, suddenly smelling the gas ovens—a smell which, more than anything else, brings back the horror of the camps. Similarly, the smell of burning rubble lingered around the World Trade Center for months after 9/11—and continued as a hallucination to haunt some survivors even when the actual smell was gone.

  There is a large body of literature on both acute stress reactions and delayed ones following natural disasters like tsunamis or earthquakes. (These occur in very young children too, though they may tend to reenact rather than hallucinate or reexperience the disaster.) But PTSD seems to have an even higher prevalence and greater severity following violence or disaster that is man-made; natural disasters, “acts of God,” seem somehow easier to accept. This is the case with acute stress reactions, too: I see it often with my patients in hospital, who can show extraordinary courage and calmness in facing the most dreadful diseases but fly into a rage if a nurse is late with a bedpan or a medication. The amorality of nature is accepted, whether it takes the form of a monsoon, an elephant in musth, or a disease; but being subjected helplessly to the will of others is not, for human behavior always carries (or is felt to carry) a moral charge.

  Following the First World War, some physicians felt that there must be an organic brain disturbance underlying what were then called war neuroses, which seemed unlike “normal” neuroses in many ways.6 The term “shell shock” was coined with the notion that the brains of these soldiers had been mechanically deranged by the repeated concussion of the new high-explosive shells introduced in this war. There was as yet no formal recognition of the delayed effects of the severe trauma of soldiers who endured shells and mustard gas for days on end, in muddy trenches that were filled with the rotting corpses of their comrades.7

  Recent work by Bennet Omalu and others has shown that repeated concussion (even “mild” concussions that do not cause a loss of consciousness) can result in a chronic traumatic encephalopathy, causing memory and cognitive impairment; this may well exacerbate tendencies to depression, flashbacks, hallucination, and psychosis. Such chronic traumatic encephalopathy, along with the psychological trauma of war and injury, has been linked to the rising incidence of suicide among veterans.

  That there may be biological as well as psychological determinants of PTSD would not have surprised Freud—and the treatment of these conditions may require medication as well as psychotherapy. In its worst forms, though, PTSD can be a nearly intractable disorder.

  The concept of dissociation would seem crucial not only to understanding conditions like hysteria or multiple personality disorder but also to the understanding of post-traumatic syndromes. There may be an instant distancing or dissociation when a life-threatening situation occurs, as when a driver about to crash sees his car from a distance, almost like a spectacle in a theater, with a sense of being a spectator rather than a participant. But the dissociations of PTSD are of a more radical kind, for the unbearable sights, sounds, smells, and emotions of the hideous experience get locked away in a separate, subterranean chamber of the mind.

  Imagination is qualitatively different from hallucination. The visions of artists and scientists, the fantasies and daydreams we all have, are located in the imaginative space of our own minds, our own private theaters. They do not normally appear in external space, like the objects of perception. Something has to happen in the mind/brain for imagination to overleap its boundaries and be replaced by hallucination. Some dissociation or disconnection must occur, some breakdown of the mechanisms that normally allow us to recognize and take responsibility for our own thoughts and imaginings, to see them as ours and not as external in origin.

  It is not clear, however, that such a dissociation can explain everything, for quite different sorts of memory may be involved. Chris Brewin and his colleagues have argued that there is a fundamental difference between the extraordinary flashback memories of PTSD and those of ordinary autobiographic memory and have provided much psychological evidence for such a difference. Brewin et al. see a radical distinction between autobiographic memories, which are verbally accessible, and flashback memories, which are not verbally or voluntarily accessible but may erupt automatically if there is any reference to the traumatic event or something (a sight, a smell, a sound) associated with it. Autobiographic memories are not isolated—th
ey are embedded in the context of an entire life, given a broad and deep context and perspective—and they can be revised in relation to different contexts and perspectives. This is not the case with traumatic memories. The survivors of trauma may be unable to achieve the detachment of retrospection or recollection; for them the traumatic events, in all their fearfulness and horror, all their sensorimotor vividness and concreteness, are sequestered. The events seem to be preserved in a different form of memory, isolated and unintegrated.

  Given this isolation of traumatic memory, the thrust of psychotherapy must be to release the traumatic events into the light of full consciousness, to reintegrate them with autobiographic memory. This can be an exceedingly difficult and sometimes nearly impossible task.

  The idea that different sorts of memory are involved gets strong support from the survivors of traumatic situations who do not get PTSD and are able to live full, unhaunted lives. One such person is my friend Ben Helfgott, who was incarcerated in a concentration camp between the ages of twelve and sixteen. Helfgott has always been able to talk fully and freely about his experiences during these years, about the killing of his parents and family and the many horrors of the camps. He can recall it all in conscious, autobiographic memory; it is an accepted, integrated part of his life. His experiences were not locked away as traumatic memories, but he knows the other side well—he has seen it in hundreds of others: “The ones who ‘forget,’ ” he says, “they suffer later.” Helfgott is one of the contributors to The Boys, a remarkable book by Martin Gilbert that relates the stories of hundreds of boys and girls who, like Helfgott, survived years in concentration camps but somehow emerged relatively undamaged and have never been subject to PTSD or hallucinations.

  A deeply superstitious and delusional atmosphere can also foster hallucinations arising from extreme emotional states, and these can affect entire communities. In his 1896 Lowell Lectures (collected as William James on Exceptional Mental States) James included lectures on “demoniacal possession” and witchcraft. We have very detailed descriptions of the hallucinations characteristic of both states—hallucinations which rose, at times, to epidemic proportions and were ascribed to the workings of the devil or his minions, but which we can now interpret as the effects of suggestion and even torture in societies where religion had taken on a fanatical character. In his book The Devils of Loudun, Aldous Huxley described the delusions of demonic possession that swept over the French village of Loudun in 1634, starting with a mother superior and all the nuns in an Ursuline convent. What began as Sister Jeanne’s religious obsessions were magnified to a state of hallucination and hysteria, in part by the exorcists themselves, who, in effect, confirmed the entire community’s fear of demons. Some of the exorcists were affected as well. Father Surin, who had been closeted for hundreds of hours with Sister Jeanne, was himself to be haunted by religious hallucinations of a terrifying nature. The madness consumed the entire village, just as it would later do in the infamous Salem witch trials.8

  The conditions and pressures in Loudun or Salem may have been extraordinary, though witch-hunting and forced confession have hardly vanished from the world; they have simply taken other forms.

  Severe stress accompanied by inner conflicts can readily induce in some people a splitting of consciousness, with varied sensory and motor symptoms, including hallucinations. (The old name for this condition was hysteria; it is now called conversion disorder.) This seemed to be the case with Anna O., the remarkable patient described by Freud and Breuer in their Studies on Hysteria. Anna had little outlet for her intellectual or sexual energies and was strongly prone to daydreaming—she called it her “private theater”—even before her father’s final illness and death pushed her into a splitting or dissociation of personality, an alternation between two states of consciousness. It was in her “trance” state (which Breuer and Freud called an “auto-hypnotic” state) that she had vivid and almost always frightening hallucinations. Most commonly she would see snakes, her own hair as snakes, or her father’s face transformed into a death’s-head. She retained no memory or consciousness of these hallucinations until she was again in a hypnotic trance, but this time induced by Breuer:

  She used to hallucinate in the middle of a conversation, run off, start climbing up a tree, etc. If one caught hold of her, she would very quickly take up her interrupted sentence without knowing anything about what had happened in the interval. All these hallucinations, however, came up and were reported on in her hypnosis.

  Anna’s “trance” personality became more and more dominant as her illness progressed, and for long periods she would be oblivious or blind to the here and now, hallucinating herself as she was in the past. She was, at this point, living largely in a hallucinatory, almost delusional world, like the nuns of Loudun or the “witches” of Salem.

  But unlike the witches, the nuns, or the tormented survivors of concentration camps and battles, Anna O. enjoyed an almost complete recovery from her symptoms, and went on to lead a full and productive life.

  That Anna, who was unable to remember her hallucinations when “normal,” could remember all of them when she was hypnotized, shows the similarity of her hypnotized state to her spontaneous trances.

  Hypnotic suggestion, indeed, can be used to induce hallucinations.9 There is, of course, a world of difference between the long-lasting pathological state we call hysteria and the brief trance states which can be induced by a hypnotist (or by oneself). William James, in his lectures on exceptional mental states, referred to the trances of mediums who channel voices and images of the dead, and of scryers who see visions of the future in a crystal ball. Whether the voices and visions in these contexts were veridical was of less concern to James than the mental states which could produce them. Careful observation (he attended many séances) convinced him that mediums and crystal gazers were not usually conscious charlatans or liars in the ordinary sense; nor were they confabulators or phantasts. They were, he came to feel, in altered states of consciousness conducive to hallucinations—hallucinations whose content was shaped by the questions they were asked. These exceptional mental states, he thought, were achieved by self-hypnosis (no doubt facilitated by poorly lit and ambiguous surroundings and the eager expectations of their clients).

  Such practices as meditation, spiritual exercises, and ecstatic drumming or dancing can also facilitate the achievement of trance states akin to that of hypnosis, with vivid hallucinations and profound physiological changes (for instance, a rigidity which allows the entire body to remain as stiff as a board while supported only at the head and feet). Meditative or contemplative techniques (often aided by sacred music, painting, or architecture) have been used in many religious traditions—sometimes to induce hallucinatory visions. Studies by Andrew Newberg and others have shown that long-term practice of meditation produces significant alterations in cerebral blood flow in parts of the brain related to attention, emotion, and some autonomic functions.

  The commonest, the most sought, and (in many cultures and communities) the most “normal” of exceptional mental states is that of a spiritually attuned consciousness, in which the supernatural, the divine, is experienced as material and real. In her remarkable book When God Talks Back, the ethnologist T. M. Luhrmann provides a compelling examination of this phenomenon.

  Luhrmann’s earlier work, on people who practice magic in present-day Britain, involved entering their world very fully. “I did what anthropologists do,” she writes. “I participated in their world: I joined their groups. I read their books and novels. I practiced their techniques and performed in their rituals. For the most part, I found, the rituals depended on techniques of the imagination. You shut your eyes and saw with your mind’s eye the story told by the leader of the group.” She was intrigued to find that, after about a year of this practice, her own mental imagery became clearer, more detailed, and more solid; and her concentration states became “deeper and more sharply different from the everyday.” One night she became immer
sed in a book about Arthurian Britain, “giving way,” she writes, “to the story and allowing it to grip my feelings and to fill my mind.” The next morning she woke up to a striking sight:

  I saw six druids standing against the window, above the stirring London street below. I saw them, and they beckoned to me. I stared for a moment of stunned astonishment, and then I shot up out of bed, and they were gone. Had they been there in the flesh? I thought not. But my memory of the experience is very clear.… I remember that I saw them as clearly and distinctly and as external to me as I saw the notebook in which I recorded the moment. I remember it so clearly because it was so singular. Nothing like that had ever happened to me before.

  Later, Luhrmann embarked on a study of evangelical religion. The very essence of divinity, of God, is immaterial. God cannot be seen, felt, or heard in the ordinary way. How, she wondered, in the face of this lack of evidence, does God become a real, intimate presence in the lives of so many evangelicals and other people of faith? Many evangelicals feel they have literally been touched by God, or heard his voice aloud; others speak of feeling his presence in a physical way, of knowing that he is there, walking beside them. The emphasis in evangelical Christianity, Luhrmann writes, is on prayer and other spiritual exercises as skills that must be learned and practiced. Such skills may come more easily to people who are prone to being completely engaged, fully absorbed, by their experiences, whether real or imaginary—the capacity, Luhrmann writes, “to focus in on the mind’s object … the mode of the novel reader and the music listener and the Sunday hiker, caught up in imagination or appreciation.” Such a capacity for absorption, she feels, can be honed with practice, and this is part of what happens in prayer. Prayer techniques are often focused on attention to sensory detail: