PATHOLOGY OF PERCEPTION

Sensation and Perception

.Scrsaliort is oniy the lirst stagc in receiving inlbrmation from outsiclc the sel[. For visual stimuli to be perceived, they must bc maclc meaninglul; ancl this is a ltroccss o[ climinating thc itrclevant, and associating r,vhat is secn with olhcr importalrt rlata to [rtrm a perceltL: sotne of whal" is roccived visually is pcrccived, but uiost ol l[c visual ficlcl is not. The distinction from sensation has been clarified by I(riiupl Taylor (1966) who identilies tlrree increasingly sophisticated stages ol percaption.

Pathotrogy of Perception
I l'lcw her body back to the IJar to be buried, because I fclt that was wherc she belonged. I coulclu't conplaiu rbont our marriage rnym(]rc then. She'cl gone and left me behind aftcr forty-two years. Wc'd lived thr"ough thick and thin, goocl times and bad. Wc'd had a rough lifc and becu lcrrced to eat tucker we ditln't like, but wc'd raised six kids and survivccl. . . .
I was lying on my becl with rny lnn ovcr my heacl when my cattlc dog gave one sharp yelp. ll'hr: kids were rll asleep ancl I didn't look up at lirst bccause I thouglrt it was probably rny sotr Jolttury cr;uring iu, us I was cxpccting hin. When I clid look up who did I scc sitting on thc cnd o[ nry bed bul. Srrsie. I wrs so stunnccl I rolled brck ancl hicl rny [ace, when I lookecl agtrin she was still thcre. Shc sat thcr:c lbr a while and ttrcn just rlisappearcrl.

'I'hc nexl day I wcnt rncl srw sornc o[ our pcoplc and tokl thcm wlrat hacl happenerl. 'l'hcy saicl, 'Yes, that's right, we seen her too'.
Later some o[ the chilclrou ancl granrlchildleil slw hcr. Shc continuccl to appcar: to cli[lcrcnl ones on antl olT in Port llcdlancl anrl Marblc l]al lbr twelvc mon[hs, ancl then she wrs gollc. l think it l.akes l-lrem that long to say goocibye to their farnily.
Sally Morgrn

(l989)

I A sensalion [.ry itself can nevel'fonrr the content oI arr cxistcnliirl cxpclierrt'c, only afiekloJ snsnions can do that'. When I am aware o[ tny sur:roundings, it is not a single sensation but several different sensations of which I am aware at the same time. I see the print of this book; I also see the book itself; and I hear the door banging downstairs; and I am aware oI the hardness of my chair. I am never aware oI one solitary sensation. They ail have their elfect with var:ying intensity to produce a.fieltl ol sensation.s. 2 A sensory perccptis experienced as 'er sensory conliguration without recogrrition'. Whilst I look at the picture on the far wall, I am also diu.rly awarc o[ what I know to be a lilrg cabinet on my right, I am concentrating on thc picture and so tire cabinet, arlthough perceivcd as a sensation, is not rneaningl'ul. 3 A rncartirrpJLi perccpt is an entity l.hat is recognizcd as somcthing lautiliar. tn thc extrmplc givcn abovc, I move my head. Now I am looking at thc liling cabiuet ancl I hnow irnmecliately what it is. I recognize it as a grey liling cabinet and Lrothing clsc,'
The Requirements for Perception
Whrt is required for pcrccption to tahe place? Irirst, to bc able to perccive, I rnust bc able to hokl mysclf distinct and in opposition to the object of perccption. As discussecl in Chaptcr 1 3, I know what is me and what is thc objecl" that I am percciving. I can rn<c rn absolute distinct.ion bct.weeu 'mc' ancl 'il"', and I arn iu uo doubt as to which
is

'['he cottscioustress ol particular uratcrial things preselt to sense is uowaclays called perccption . . . if' we look at rn isolated printccl worrl rurd repeat it long enough, it ends by assuuriug au entircly unrraturrl aspcct. Let the rertlcr t.ry this with aly wcrrd on this pagc. IIc will soon begiu to woncler if it can possibly bc the word hc has becn using all his li[c with thal, urcaning. It stares at lrim frcnr the past likc a glass cyc, with no speculrtiotr itr it. Its body is iudcccl there, btLt ils soul is flesh. It is rccluccrl, by this new wtry ol' attcnrliug l-o it, to its csscntial uutlil.y. , . . Wc arprcherrrlecl it, in short, with a cloucl ol irsstciatcs, and thus perccivirrg it, wc iclt il. tluil"c otherwisc thur as wo lecl it now

which.
Sccontl, I and thc object ar:c hclcl togel.hcr by movcmcnt of myscll' towrls thc objcct,

divcslerl anrl akrlc. William Janres (1t390)

Ihe movcmctrt may be litcral, physical ruovernent: I go ucarer to it iu oldcr to ltcirr t|c
noise that comes liorn it. It muy be movcment in thought: whon I irrvcstigale thc object, my thinking is moved from anothcr arer o[ contcmplation kruzrr,ls thc objcct, ancl so thc object and I bccome couplcd - object and perccivor of that objcct. lfhird, thc object must holcl some challengc to be explorcd. It is ouly the lirct that the object is different from the other possiblc objects oI perception which tonch it in

With varirtiors ol norlnal pcrccptunl cxperielcc bcing so straugc

two vcry dif[errcnt tccoullts, it is not surprisiug thrt thc psychopathology is also very varied. Wc will lirst looh at thc phenornenology of the process of normal perception and therr cottsicler thc rarnge o[ abnorrnalities that occur in the morbid state. 'llhere can be fcw areas where the work ol' assessment by the psychiatrist is more misunderstoocl than in the psychopathokrgy of perception. Thcre is a popular misconccptiou that 'hcaring voiccs' nccessarily iruplies auciitory hallucinations anci tllis, in ils turtr, irnplies serious mental illness, probably sctrizopluenia. I hope that it will be clear I'rorn this chaptcr that such r notion is simplistic, that hcalthy pcople and those without psychosis not infrcclucntly dcsclibe 'hcaring voiccs'. It is important to rssess thc rttturc, thc./bnrr o[ the inclivirlr,ral's subjccl"ive expcricnce, ancl not just carclessly kr rccorcl thc worcls thc paticnt uscrl or impliccl. I'hcnomcnokrgically acccptabic auditory hallrtcilations occur in otherr couditicurs as vvell as in schizophrcnia.
as these

timc or spnce that mrkes it delinitc, and thercfore a possible object o[ pcrccption. l['hc self can be, of course, both the perceiver and the objcct oI pcrccption. We Lrc concerncd in this chapter with abnorrnalities o[ perception in which therc arc disorck:rs in thc subjcctive aware[esri of cxperience.

Sense Perception and lmager),

Our awrLcucss ol'objccts is of lwo kincls,.sclsr per:tti<ut lurl irrro,r7. A rr:rsou rronnally has no tlilllculty irr clislinguishing bctwccn [lrc [lvo: iurutctlialcly utrl lvith 9t

90

SYMPTOMS IN THE MIND

PATHOLOGY OI. PERCEP'f ION

ill)solutc cer"tainty hc hnows whcthcr he is pcrcciving real objccts or inraginiug t.hcnr. Scnsc pcrccptiou is cxpcricncccl as being lcal and lhcrelbre to be actecl on, irttirgery (Jiurtasg) is creatccl voluntarily by himsclf and is not real in the sensc of exterual perception. I can crcrte an elaboratc fantasy o[ an enjoyable meal, even to thc extcnt o[ making mysclf salivate. I-Iowcver', I do not havc the slightest difliculty itt kuowiug that the mcal is not thcre and my feelings after letting the fantasy g<l are not at all likc the feelings of having a real meal removed before eating it. Other subjcctive cxperienccs o[ sensory objccts rre assessed according tr. how they approxirntte lo thesc two and this is shown in ligurc 7,1.

"&A: Figure

7. I Modes of perception

Sense subjectively perception =

Hallucination

should ilot bc acccptcd at Ihce valuc, I{e is morc lil<cly to lrc cornurcrlig t[al. |s has inlrcquent visual images; just as likcly, howevcr', is the failurc to rccognizc rcluerllbered irnages as fantasy, or preventing lantasies, eithcr by reprcssivc scl[-ccns6r-sip, or bccausc of lach of affect secondary to depression. such a pcrson is :rblc to cxper-icncc in his mind the irnagc oI a holly bush and describe it. Ile docs not rcrlizc, however, that this is fantasy or imagination. Il he is deprcssed, the cxercisc becomes vcry difficult in the same way as memory is described as bcing 'poor' through prcoccuprtion with gloomy thoughts. when somcbody dcscribcs a sensation that they expcrienccd in thc past, thc irnplication is that thc following steps have takcn place: at thc timc, he pcrccivccl thc sensation as meaningful and recorded it, and then the act of nr.cmorizing that allows him to reproducc thc perception (thc ability to trke this imagc li.om storerl clata into I'ull pictorial consciousness) is, in phenorncnological tenns, [antasy, That is, subjcctivel, [11nry ard m:mory for pcrccpts are idcntical. This is not thc only roule by which fantasy occuus. Sottrc cvcnts are :ecortlccl wilhorLt being perccivccl as urca-

ingful. Thc strbjcct mattcr of drcttns may somctimcs br: brscd on thc lcrory ol'
Pseudo

hallucination

such scnsal.ions. Irautasy is volitional: thc subject is able to collcct cliffercnt rcprocl"rcccl pcrccptios ilr different sensory rnodalities and fi'otn dilerent l"inres, anc] clerte r single corrgsite present fantasy experience, that is clay-dreaming, Even at the timc whcn the

initial perception is formcd, one of the things that distinguishes perception lrour
sensation is the fact that perception is always acLnixed with luntasy. Thc prisouer 'notices' the hole in the floorboard because of his fear that rats may inlest thc cell at night, sensory perceptions and fantasy can therefore never be complctely separated.
lmagination

(fantuy)

Abnormal Perception
fantasy.

On iutrospccting wc can clistinguish letwecn scnse pcrccption and

llowcvcr, in cveryclay lile the two are nixecl. Intrinsic to our 'worlci' is a mixture o[ l'antasy and l'rct. When wc buy an airlinc tichet, we not only 'buy' a passport to travcl, we also 'buy' arr image o[ ttrc acroplane and sundrerrched Mediterrancan
bcrchcs.

wc will now divide abnormal perception into

scnsor7 distorliorrs, wherc a rcal perccptual olrject is perceived distortccl, and/isc pucttttiotts, whcrc a ncl pcrc:c;tio occurs which nlay or rnay not be in rcsi;onsc to an extcrnal stirulus. Illlsios,

Our actions are lbunded on this combination o[ percept and irnagery.

llr.;.llucinatiotts and pscudo/rallucirlfifions

will

be inclucled uncler lalse pnrceptions. TI're

Fantasy: lmagery
William James (1890) described'the strearn ol consciousncss'in his book
Thc

Prilu:iplas oJ Psycholop1y.This dcscribes the highly complex experience which we have whcn dircct perccption is mixed with the intcrpretation of these perceptions: intru-

sion ol associatcd rnemories; fantasies; evanescent sights, sounds, smells; and so on. I'husfiurfasy is an essential part o[ r pcrsor.r's ougoing mental activity. Fantasy may involvc arry o[ the live scnses, but espccially vision. Ilowcver, 'an important part of humau thotrght involves anticipating sets o[ intentions which themsclvcs rrc not ortlinarily rc[lectcd in direct inrages' (Singcr, 19tj1). Pcoplc vary considcrably in tl-rcir capacity for day-drean-rs and also in their predorninant content. Nonnativc data would suggest that, in gcneral, a richness of [antasy lifc is associated more with satislaction with lit'e and cmotional stability rather thrn with neuroticism. However, a patient's staterncnt that he has no imagination

possibility of a neurological deficit affecting percepl.ion also necds to be consiclered. Snbjectively, ltallucit'tqLiott is similar to sense pcrception: it is experiencecl rs r rrortttnl perception, and it can be distinguished frorn the fantasy elcments that invest it. In vivid ilrngery the wholc experience is imaginary. Psetulohlhtciurrfior has a closc aflinity to imagcry but also has some aspects which are characteristic o[ seuse perccption or hallucination: vividness, definition, constancy an<.1 apparent independence from volition. In the experiences of illusior, Jarus (iirrngcry) urakes a signilicant contribution.

Sensory Distortions
l)isturbancc ol' the mcntal sl.atc, with or without organic brain patliology, l)ray crsc sensory disl.ortion. This distortiou miz iuvolve: (tr) thc intcnsity or (b) Qullity 1l cccption, (c) thc feeling associated with it and (cl) splittirrg of pcrccptiorr. I{cre is a description of multiple clistortions of pcrccrl.ion and clisturbancc ol scll'-ilagc
93

92

SYMPTOMS IN TIIE MIND

ATHOLOGY OF PERCEPTION
(LSD)

cxl)oricrrscc by

psychia{.risl. who was adtrtinistcrcct lyscrgic acitl clicthylamirlc (Wilkiuson, 199l).

ttcutc schizophrcnia, ancl occtsionrlly with neLrroses. With mescrlirr, rarts o[ l|g botly rnay tppcar sevcrcd or clctachctl in spacc. Ch:rnges irr thc colotrr ol tcrccivgrl
objccls niry irls<t bc clcscribccl with mcscalin, or a[l.cr Illiirrg nrcscitlin.

twill tr.ylorltrscribcil.,bul,il'stlillicrrlt.Mypcrt:cpt.s,tltcvicwoIlltctlttor,tlrcvicwol lllc

tablc sourclurr,v [rct.anlr: nu:. Il souu:torly lcll. tlrc rooru. lirr cxatrlple, lhcJ' disapllcrrtxl: I r'vas btlrelt I Irt:y coasgl o oxisl.. l]t'causc I [ratl pcrr:ivl tIrr:trt, tlrt:y wcrc rarI ol. ttre tttttl il' tlrcy lelt.'llhis was tlrrcaterrirtg atttl worryiug.
At. thc trcigtrl ol t[c cxpcricncc, I rlccirlctl il. was too lnltch to copc with, so I closctl nty cyes, r gfcat lnistakc. llccausc rll vistral pcKrcpts tlisarpearcd, I felt i was breaking up, that thc cgo l4/as sotnchow going r-rp the cltintucy.

Chonges in the feelines ossocioted with perception

Pcrt:cption is acconrpanicd by affect. which may bc a lccling ol tirnriliari{y, ol' cLrjoytucnl,, o[ dislil<c, of involverncnl., of proximity, ancl so on.'J'his is usually appropriatc, and so ignored. Howcver, changes in these feelings rlur prcsent as sytrtp[oms, lbr cxample'evcrything looks clear but it all looks miles awtry', 'l [ce[ in scclusign. lt is lilic Iooking through thc wrong end ol a telescotc'. Thcse, anrl rnaty othcr fccliugs, are described Ltncler drurtlizriiorr (Chapter 14). Thcrc is a feeling of r-rnrcality in thc pcrceptual liclcl, an alteration in lhc f'eclings assoclatcd with the objects o[ perccption. A patient who exemplified both the loss ol intensity o[ sensation and thc changc in feelings associated with pcrception iu thc context of a deprcssivc illness was a 23year-old sri Lankan Buddhist priest. Foilowing a session ol meclitation, he bccame vcry frightenecl one night after assruiting another you]rg p[iest, apparcrrtly in his slcep. In the next [ew days he fe]t that he had lost all scnsation.'I'lrings llc saw arrrl hcard he could not understrnd properly. I-Ic coulci sec only thc things that r,vcrc ncarby. I{c could rrct get any sensations ['om his skin. lIc saici that hc cculcl nol rc:acl nor unclcrstrnd, nor I'eel sidness or happincss. He said that he couicl not t'ecl anything 'all is nnrnbed, bocly and mind'. IIe admitted to I'ccling lor,v, that lit'c was not wol-t|

.l'hal. wts so lrightc[ing,

I opc[etl my
ttter:e ,

iunrbted, but at lcast it was

srw

antl I

wts

eyes again ancl sarw evcrything rlistortecl and there agaitr'

I bclicvc I rcalisccl lbr thc tjrst tirnc whrt a patient witLr schizophrertia meaut whcu he sollleollc hamnror a nril into ttre wall ancl sritl 'Ttrat uail is being hamtncred illto
nry hearl'. My cgo bounrlarics hacl clissolvccl. I wrs thc wall, thc tablc, everythitrg around nre, antl thc two things wcrcr iDclissolublc. If ttlcy were al'bcted, I was rllccted.

'l'[rc irllpor-tancc ()[ that exircricncc [o nlc wls VCry

P,rcal. loL twt rcasotls. I ltow Ilacl sonrc pcrsonal unrlcrstanclittg ol t.hc psychopal.trokrgy o[ psychotic illur:ss - or:gatric statcs id scfiizgphreic states particularly. z\rrd secondly, I rcalisccl that one's cvcryclay cxpcricLrcc ol thc worlcl is irliosyncratic alld probably uot sharccl by anybocly clso.

NJ

but I lror. thc prrrposcs o[ cxrmrnuniortion, wc lssllllle wc all sec things iIl a sinlilar way, clol't bclievc this is tl.ttc. LSD gavc rue a subjcctivc view o[ pcrsr-rnal psycl'rology arld a

&"!:"

rvilligness to try aucl livc into thc world o[ thc psychotic patient with a now scnsitivity.

living ancl hacl thought of cnding his tilc. There

physical abnomrality.

wrs

no ncurological or olhcr

lntensity and quality of percePtion Tc irrtcrisify ol' pcrccption may be altcred so that it is cithcr heightcnecl or ciirninishctl. tor cxalnple, heightcning in thc auditory modality is callccl ltypct,rr'risi.s: a

The affectivc concontitants of perception in paticnts with schizophreuia r,vcrc

invcstigatecl by cutting (1981). FIe showcd that a group o[ raticnt.s with acute schizopltrenia differccl signilicantly from thosc with chronic schizop]rrcniu, dcprcssion, or l.hosc with tleuroses or personality disor:clcrs, in judging whir:h ol' two lirces in photographs was thc more li'iendly. On r control tasli of jr-rdging colours the rc was no cliffclence bctr,r,een the groups. In a furthcr cxperirncnl., rcute scrhizoplrrcr-ric ratienl"s wcre difl'crcnt li'orn paticnts o[ other diagrrosf.ic gloups in jr-rdgirrg f iend]incss itncl ntctnress of faccs, br"rt agrccd with theur r judging the irgcs ol thc lir:cs. This wor-rlcl suggcst that the tiisturbtlcr: in schizophreuics is r,vith Ihc nxraning atrd associatiorr of perccption, rrthcr than in the plrysical captrcity to pcrccivc. I'he underlyin g ntoocl stulc profouudly aff'ects pcrception. For example, a cleprcsscd paticnt saicl 'Thc lieshncss is all gone. Things no longer appear cnjolrable . , . I ar dcad. Li[e around me has tsolutely no meaning.' In r:sfnsy sfurfc,! a quitc <-rrclinary perception may be transformcd to become absorbingly beautitul. A boy who hacl taken LSD did not experience dclusions or hallucinations ancl was not marhedll, altered in mood; however, he gazed abstractedly rt where thc dull clirty pinli o[ thc hospital wall merged with the dull dirty cream o[ thc I'rospital cciling, quite absorbcd by the beautiful contrast. of coloursl

syrupt.orn il] which the patic[t cor]lplains of ever:ythi[g sounding abn<lnnally loud sayiDg 'I cur't. bear thc Iroisc'. Ordinai'y co[versation mly sollnd intolerably noisy' aricl even whispcring at a clisl"rncc lnay be founcl uncomlbrtablc. Thcre is, o[ cottrse, o t.ruc iurprovcmcttt. of atrclikrry pcrceptbn but sinrply a lowcring clf the threshold at whicS oisc bccomcs ullplcasallt. '['hc symptom occuls il] tlcprcssiou, migraille

an(l somc toxic

stLlcs,

lol exarnple, t]ro /tnttgoucr lbllowing acute alcohol crxccss.

atccl wit.h ccstasy cxpcricnccs, rncl lnay occur in the organic psycilosyndrolne calrsed by LSD rcl[rinistration, in [unctkrnal psychoses espccially manil, and occlsionaliy with epilcptic aura. Intcnsity o[ perccption lnay be lowerecl in clepression 'cverytlling looks black" Cornplaint may bc made l.hat all food tastes the sal11e, or that sounds rre muflIccl, quiet ancl [lollotorlolrs. It is an altcration of perception, but not ln impairmel]t. of t5c sense organs. llor example, the patient who snt cvcrything 'blach' was st'iil able to icll thc colour o[ 6bjects atrd ctrrry ou[ colour matching accurrtely. Intensity may be describccl as paintul, as in llyperacusis, or the normal pain threshold of sensrtion rnay bc lost so that pain is rlo [elt. :l'i',.,,. n1ny bc altcration in the qrurlit7 of pe fccptiotl. A change of perccivctl shtipe is sometiles clescribe{ wit.h parictal lobc lesiorrs. lu rt.titlt"opsia, objccts secm sluallel tlra their rcal sizc, i ttlu(x'opsia, larger, ancl i tllsttrcalotsiu, larger on onc side than the other. 'l'hcse corxlil.iors occLlr iu acr.ttc organic states, epilcpy, vcry rrrcly ill
94

VistrI1ptrotshcsia occurs: cololrrs iooh ntore intcnse or vivid. Tl-ris n'ray bc Lsstlci-

Splitting of perception
This rathcr rare phcttomettorl is dcscribecl sornetirncs,with organic states, ancl rlso r,r,ith sclizophreuia: the patieut is unablc to lbnn thc usual. assturerl linlis lrctwccn two or tnorc perccptious. A paticut wilLchng telcvision expericncecl a t'ccliug ol colpct.ition bclwccrl lhe visuttl antl auditory pcrccptiors. Sllc I'clt that ttre two wcLr-r lrgt
95

SYMPTOMS IN THE MIND

PATHOLOGY OF PERCEPTION

fror the satne source but were compcting for her attention and convcying opposite mcssagcs. Splitting oJ' lterception occurs when the Iinks between different sel)sory moclalitics fail to be made, and so the sensations themselves, although ill fact
cor11ig

fiuished pattern (Beveridge, 1985). It is necessary for us to mihe scttsc of oul euv!

ronment; when the sersory cues are nonsensical, we alter thern slightly with remembeled or fantasy matcrirl, so that the whole perceptual expct:ience bccomes
meaningful,
When illusiorr arises through allect, perception of everyday obiccts is changed. The illusion can only be understood in the context of the prevailing mood stat.e. A child who is frightened of the dark wal<es up in the half light and mistakes a towcl hanging by the wall for a person moving. The experience only lasts a short time rnd disappears when the intense fear goes: the iliusion is banished by attention. O[ course, there is no absoiute distinction between these diflerent types of illusion, The degree of completion, or of affect involved, is variable. For example, a man loohing through advertisements for a post, found a job that he lil<ed and misread the written word 'suitable'for the illusional word'superior. . . applicant is required'. Clearly this was both an affective and a completion illusion, Similarly, in thc stage o[ senrcfiirlg that occurs following bercavement, momen[ary recognition of tltc dcacl pcrsoll lray occur lbr someonc in r crowd. Close .bservat,icn ol' thc individual imntcdia{,cly clispels thc feeling o[ farniliarity. Parcklolio occurs in a considerable proportion o[ nornral pcoplc. It may also bc provoked by psychomimetic drugs. Typically, itnages are seen from shapcs in parcidolic illusion. Ior example, the author used to see the hcad of a spaniel in a chip on the first paving stone of the path leading to the house where he livcd as a child: the image was not just a dog, but definitely a spaniel. Pareidolic illusions are created out of sensory percepts by an admixture with imagination, The percept takes on a full and detailed appearance - 'a Victorian Iady with a crinoline and frillcd bloomers'. The person expcrienciug it, like someone seeing a photograph, knows that it is not truly there as an objcct, but that it is pictorial, Flowever, he cannot dismiss what he sees. Cornpletior and a[fect illusions occur during inattcntion; they are banished by atteution, which will, i[ anything, incrcase the intensity o[ parcidolic illusions as they becotnc tnore itttricate irntl dctailetl. Pareidolic illusion occurs in childrcn more than adulls. Il. should be distirrguishcd froln the lollowing conditions.

trlN'

rrssociated. appear to be quite

seprrlte , tnd

even in conflict'

False PercePtion
Now we turn from the altered perception o[ real objects to consider the perception of objccts which are not there, these are new perceptiorts which include illusion, hallucination and pseudohallucination. Illusions were separated phenomenonologically from halluciations by Iisquirol (1838), and later also by l{agen who introduced thc term pseurlohallucination (Berrios, 1996). He described them as transformations of pcrceptiops, coming about by a rnixing oI the rcproduced perceptions of the subject's I'iurtasy with rtatural perccpt,iolrs.

lllusion
l'lrrec types o[ illusion are normally clescribed:
ttu^eitlolic il,lrsion. cotnpleLiort illusior, aflect

illusionand

Courplction illusions dcpcnd oIr inattention for their occur:encc' The laclcd lettcring o[ an advertisement outside r garage is represented in Figure 7'2' Being rnore interested in music than crrs, the author regultrrly misread this as 'Vivrlcli'. We cornmonly rniss the misprints in a newspaper because we read the words as i[ they were writte correctly. As soon as our attention is drawn to the mistake our pcrception alters. An incomplete perception that is meaninglcss of itself is filled in by a process of extrapolatic.rn from previous expcrience to produce signilicance.

Figure 7.2
llh-rsion

vl/ALDI
vw/AuDl
VIVALDI

I Pcrceptual nsinterpretation, that is, simply making a mistake as to the nature of perception without that perception being particularly influenccd by cmotion mixed with fantasy. 2
Ftutctionallmllucination, which occurs when a ccrtain percept is necessary lbr production of an hallucination, but the hallucination is not a trarrs[ormatiort the of that perception. For example, the patient hears voices when the tap is turncd on; he hears voiccs in the running water, but the voices and the noise o[ water are quite distinct and can be heard separately and synchronously like trny otller voicc tl-rat is heard against a bachground noise. Thc perception o[ l-rcaring ruuuittg water is necessary to producc thc hallucination but the hallucinatiort is uot a translbrmation of that perception. 3 ltantastic interltretatiorts or elaboratc tl1-tlremnhry can be vcry siuilar lo pareidolic illusions and, as we have alroarly discusscd, there is a largc acttuixture oI fantasy in such illusions, 97

complction illusion demonstrates the principle of closur in gestalt psychology (see chapter 10): there is a human tendency to complete a farniliar but not rluite
96

SYMPl OMS

IN I'HE MIND

PATHOLOGY OI- PERCEPTION

ri

l{a!lucination
false pcrccpilallucinations are, phenomenonologically, the rnost significant type oI hallucination' o[ iuus. IIerc arc five clelinitions
f

to attribute them to an cxternal sourcc. The content of hallucination was l hought lo be explained, at least in part, by the need to clelend the incliviciual's owl sell-esteem.

I 2

(Jaspcrs, 1962)' occnr simulterncously with ancl aloltgsiclc real perceptiorl pcrcept which clocs not irltcroccptive or 3 Al] hallucinatkrn is rn extcroccptivc (Smythics, 1956)' objcct courespontl to an actttrl 4 Accorclirrg to Slrclc (1976a) three critcrit are cssenti for atr operational def'(b) perinitio[: (a) pcrccpt-lilie cxpcrictlcc ill the absence o[ tn cxternal stimulus; and perccption: a rerl of ccpt-likc e,*p",,icncc which has the tull force ancl impact ctnnot antl spontancoltsly occlrrs is u,wiilccl, (cj perccprlike experie'ce wk:h bc rcadily controllecl by the pcrcipieut' A lrallucinal.io is i.t pcrt:clttiotr r.vithorrt an obicct (within a rcrlistic philosophwithout anll corical lirnrework) or the appca rattcc o! an hivitbtal thing in tlu world

A pcrccption without an obiccrt (Esquirol, 1817)' distorl{allucinations propcr rre false perceptious which are not in any way rs sol,cthing quitc new and own thcir up on spriLrg but perccptioris of'rcal ti.,s

Ilailucinations may rcsult from a failure of the mctacognitive sliills involvecl in discrimi[ating between self-generated and externrl sourccs of infoati6. This explauation was given furthcr support by ttie finding that halluciators more ollerr misattributed auditorily prcsented auswers to diflicult clues to an expcrirlentcr thar either a deluded but not hallucinrted group of patients or uonnal control subjccts
(Berrt.all et al., 1991). Atl.e[rpts l,o cxplain hallucinations in terms of undcrlying ncurochenlistr.y autl ncr"rropart.hology have so lrr not macic uruch pfogress. An attempt ]ras becrr rnarle to
.

rcsrorulirrg umterial cvrrl

(within a I(antian frarnework),

accorcling to Cutting'

t997.
abont hallucinations is olten oue of tlic most clifficult to is :t rtol' conrrrchcrrcl.'Itrat is, to ihc paticlrt, what thc itoctor calls an hallucrinatiori is intlistinguishable hallucination an tirerelbre, ,,r,,1 ,c,,.rory c.rpcrricrrc. subjcctivcly, be hallucinatccl is Ii:om a norlmal pcrccpt..'llhe oflly clue to the sulfcrer that hc might A lvotlan rnodalities' perccpt in other thc lbr cvidcrrcc corroborttive is n0 thaL thcrc s]ie is going thc sink' 'she to is hcars voices giving a commc[tary on hcr: activity: o[ voices the recognizcs btlt rootn the putting thc cJt'fee n'. She sces ro-one clse in is so she but thcm, heariug be can she how ircr ncighbou.s. Shc cr.not unclersta.d and trkes f'he mircolvinJecl by the reality o[ thc voices that she draws the curtains voices but can see no hears she rnilld' in her conflict is some Therc walls. tlte rors off pcrsol to rccount [or: them. However, she resolves this conllict in what is a rrtional iuy, ns..,.rrring thart she believes implicitly in the genuineress of the perception: '.urr-,.urr" must hrve fixed a clevice or altcrccl l1ly selrse of hearing'. She does not
Orrc

of thc simplcst

lrcts

incorporatc concepts of biological vulncrability and psychological inllucccs i thc aetiology rnd clinical presentation o[ hallucinatious, but l'cserrch fias proclucc o single mccharrism to accor-rtt lbr thcm (Asaad ancl Shapiro, 1986). I'Iallucinations can tal<e place at thc same time as normal scnsory stiuli rrc leccivcd. In this way thcy ale unlihe dreants, which in lirct have mgre ol' thc characteristics of illusions. Flailucinations are likc normal percepts, oI lvhich sevcral ca lc perceivcd sirnultaneously or in rapid succession. T'hus, the patient calr hcar halluciLratory voices at the same time as he is seeing his interviewer and listening to him speak. Ilallucination is like n/ter hnnge, paraidolin or the observation o[ a noal sensory object, in that attention will not removc it. I'hd scnse o[ reality expcrienced by patients whcn they hallucinate has bcc str-rcliccl b, \ggsrracs (1972), dcveloping the conccpts oI Rrsmussc1. LIc lrointcrl or.rl six qualitics of which normal pcople can be awarc whcn frey expericncc a scnsatiou, which also occurrecl in over 90 per: ceut of a serics c[ hallucinations,

I With normtl scnsation we trc able to distingr-rish pt:rt'citittq with olr scnsc organs li'orn inurginilry the same objccts; haliucinations similarly arc expcrienccrl 2
not tlrcu1ht or Jatttasy. When a subject expericnces somcthing, he reizes its possiblc re/'r,nrrcc ['rr his own emotions, needs or actions; hallucinations rlso hrve this qr-rality ol'
as scnsnf.iorr inci

4#r t Iur,,ui ttCi

ckrtLlrl

Slhas investigated hallucinatiotts using tr cognitive approach' lookrnd transirrg ai cach o[ thc [ollowing lbur constructs in tcrms o[ coding, appraising

thc percePt.

[irrtrring ittlbrtuation.
(2) are tlerived llallucinatioDs arc rucntal iruagos l.[rat (I ) occur in thc lbmr o[ iDrages, lrollr extcrnrl rs i[ incorrectly (3) arc appraiscd li.0ur iDtcrnrl souroes oI inloruration, lour constructs sourccs ol info|matiott, antl (4) usually occur intrusively. Iiach of thcse tlrey contprisc a .clcrs lo ir scprrrlc sct ol psytlrologicirl pruccsscs. irlllltruglr lugctltcr ltolislit'expcricttcc.

\]J '\\Y tr+

Ttlis provicles a conccptual frarncwork for invcstigating the phenornena

itiou.

01

hal]ucin-

behavioural relevrnce. 3 Normal sensation has a quality of oljet:tittit1 in that the experiencer. f'eels that under favourabie circumsturces, he would be able to experience the sarnc sornething with another modality o[ sensation; this is also the experience o[ the hallucinator. 4 An objcct is coniclered to crist if the obscrver feels ccrtain l,hat it siill cxists even though nobody else is expericncing it at that time; pcrceivcd objccts and hallucinations share this c1uality, 5 Iixpericnce ol clbject perception and halluciurtion arc il,ohuttar1 in that tfic cxpcricncer feels thaL it is impossible or extremely difficult to alter or: disriss the cxpcricnce simply by wishing to do so. 6 Norrnally the experiencer is awarc, or through sirnplc qtrcstioning becomes rwarc, that his experience is not simply thc rcsult o[ being in an unusu urental statc; this quality ol indcperulencc is present with norrnal pcrception and with hailucination.
One further quality of normal object pcrception was found to be rbsent morc o[ten than not with hallucination. This is thc quality of pulllicrrrrss in which the 99

that halluTiris iclea has bccl {evelopecl further by Bentall (i 990) who consiclers tending perceptions, their of juclgeruents origin Lhc iout faulty oi,,rtio1s rcpresent
9B

SYMPTOMS IN THE MIND

PATHOLOGY OF PERCEPTION

woulcl cxpcfiencer woulcl be awrrc thrt anybocly elsc wiih normal sensory faculties others that bclievc not does be ablc to pcrce ive this sorncthing. ollen the hallucinator coukl shar.c his expericnce (clelusional explanation may be given for this). their clcarly, cultur-rl factors inl'luence the mlnnef in which subjccts describe (19tt8) because patients that Andrade by claimeci bcen has It percepl.ions. irbnornral phenomena, irr hrcliir were more preparccl to ncccpt paranormal explarnations lbr

ascribed with obiectivlirlsc pcrceptioDs or'true hallucinations' are n1o:e likely to be qualities describecl by provcn, the not it is ity ancl veridicatity. Ilvcn if this is so, ancl

Aigc,rcs woulcl still be useful in recog,izing hallucination lror other abno.nrlities

of perception.

'[diz -

Auditory Hal!ucination
also with Ilallncinations can occur in a[y of the areas o[ the live spcciai senses rnd as they are lnlhtcitttttions, ttditory discussing by sttrrt will wc somrtic sensation. auditory the most often of supreme diagnostic significance. In acute organic states, or lrallucinations are usualiy unstructured sounds - elenwrtary lullttcil:r';.tiotrc' or music. machinery whistling, or rattles, example the paticnt he ars whirring noises Of interest are Olterr the noise is experienced rs very unpleasant and frightening. or brain deafncss with womcn in oldcr cccur to tend which ntusicnl hallucinations 'l'here are, therefcrre' clisease rnd o history of psychiatric illness (Berrios' 1990)' on visurl similarities with charles I"onnet syndrome, clescribed below in the seclion

'an upper class voice'. Subjects heard a mean of 3.2 dilferent voices and usually knew the identity of at least one, in half of the subjects the voices signifiecl lulccs o[' Good or Bvil. I{alf oI the subjects were ablc to exert some control ovcr their voiccs and two thirds had developed coping mcchanisms to deal with them; high levels ol' distress were found among those with little control and few means o[ coping. The majority of subjects ascribed reality characteristics to their voices. A long history of auilitory hailucinations tcndcd to be associated with more hallucinated words, more voices, r greater range of emotionai exprcssion and grummatical style, and greater tikelihood r.rf intcrpreting l,he voiccs delusionally. Auditory hallucinations in schizophrenia are generally private events, but sevcral carly writers observed vocalizations which corresponded with the content of the voices taking place at the same time as the hallucinations. Normal people occasionally vocalize their own thoughts sotto vocei in the psychotic equivalent o[ this, it seems that sometimes those with schizophrenia are vocalizing their halluciuations at the same time as they experience them. Green and Preston (1981) increased the audibility o[ the whispers of such a patient to an intelligible level using auditory
i

I'eedbacl<.

hallucinations. in I.Icaring voices is, of course, characteristic of schizophrenia, but also occurs psgchoses occaallbctirte ot irallucirrosis alcoholic e chrotlic for exampl other conclitions, unfortunatcsionally. These voices are sometimes called phonerrres (confusion exists, where ly, becuse the word is used with a totally difierent meaning in linguistics, in ustrally made). are words which from pho.r"*., are the units of speech-sound to the spoken often Sentences, short or words simple are organicstnts the phonemes pniie,rt in thc seconrl person either as peremptory orders or abusive remarks. Thcse more comabusive or imperative phonemes also occur in schizophrenia, but other female or or male multiple, or plictrtecl speech is also ircarcl; the voices may be single experiarc They known. paticnt or not the by Loth, people known anci recognizecl

rctions or voices, which nr17rlrr or di.st'lrss vigorpaticnt in the third pcrson (Schneider, 1 9 59)' to the rcfcr ously witft caclt otlrcr.Thcy W In r series of 100 current paticnts experiencing auditory hallucinations' all o[ which were clescribccl as'hearing voices" 61 sufferecl from schizophrenia ancl 78 per cent frorn schizophrenia-related conclitions (Neryani rnd Davld, 1996)' Fifty-two rrurtrirrg cottuucrtttu.y

and defcncc,i as coming lrom outside his hcad or his self. The voice is clear, objeciive same time tile at pcrcept wirich a normri paticnt to be the by is rssumecl antl iuitc, o[ may be balltirrg ao,l in"onrprchensiblc irr its irnport. I']articularly characteristic givc a which loutl, out tltotrglrts patient's owil si:tzophrenia are voiccs which say thc

o the patient's

churning of thc patients hrcl an cxperience oI sadness and 45 per cent experienced in conspoke voices Most onset. before at or stomach the in or br-rtterfly sensatio[s sample heard the of half shouted, a few and whispered few a but tones vcrsational a their voices through their eil's as external stirnuli. Most voices were malc, often example patient, for the from accent [riclclle-agecl man, usually spcahing in a ]iffercflt r00

Sometimes patients with schizophrenia describe abnormal.perccptions in both the visual and auditory modaiities. The examiner should be careful not to rssLrnle that tirere are both auditory and visual haliucinations prescnt; ther:e may be a diifcrcnt/orrn, palticularly for the visual experience. A man, aged 45, clcscribcd his experiencc as follows 'I hear rny nephcws talking [about me] "hc is a poofter (homosexual) and a pervert" . , . I see them as well. The curtains move and I know that it is them moving thcm.'This is a description of a persecutory auditory hallucination but the visual experience is a delusional inter:pretation of a normal perccption, lot a visurl hallucination. Patients' descriptions of their phonernes vary greatly. Somctimes patients talk openly and quite blandly about their 'voices'. Not uncommonly, a patient may deny voices but assert that he hears'spoken messages'or'transmissions', or sorne other spoken souncl, and it may be difficult to decide whether this is a real perception or arr auditory hallucination. The phonemes may be so insistent, cornpelling and intercsting that ordinary convcrsation with thc doctor is found boring, and cvcn unrcal, in comparison. The voices may form an insistent background to lile, so ensuling that a largc part of the patient's speech and behaviour is occupied in answering and obeying thc voiccs. Psychiatric nursing staff often observc that thc audil,ory lrrllucinal.ions rlescribed by paticnts are as real to thern as any other remcrrbercd conversations, and both haliucinatory and rcal auditory perccrtions firrm thc memories on which patients base thei: lit'e ancl behaviotrr in the pre'sent. Auditory hallucinations occur when there is a corlbination ol vivicl mcntal imagcry and poor reality testing in thc auditory rnodality (Slade, 1976b). I'iris iras been investigated using a battery o1' tests including the verbal truusfortrntiott c]tect. The word 'tress' was repeated on a tape recorder to the subjccts for 10 minutes. Alter a time, subjects began io hear other words and syllables. Normal subjects ar-rd schizophrenics who were not auditorily hallucinated usually heard words that werc phonetically linhed to the original monosyllable, but psychotic patients who were auditorily hallucinated heard words that were quite dilf'erent. phonetically as often as those that werc linl<ed.

l0l

SYMPTOMS IN TFIE MIND

ATHOLOGY OF PERCEPTION

o[

pi'.",ri"

uot the dcgree of cxtcrp,,trc1ts with alluciatigrts, il. was [<tund thrt it was but the utt'urc of the hallucinations rrirl st.imulatioll that was rcxtrttilctl to dimitrislt monitoring ol' mrtcractivc When rcccivecl. it stiu[rlus arrcl {.hc cicgrce of attcntion

ll,appcarsl,Iratirtrtlitor:ylrallucinatiorrsarcclepcnclerrtuponthcrncaninglulncss input wcrc pl:cscnted to schizoscttsory in;ut.' Wltcn uttrious l'ypcs o[ auttitory

ialwasr:equireclbytlrcsubjcctreatlirrgalotrclapfosepassagcarrddecidinglhcconexpericncc than tc,t alterwarils, this proclulecl a grcater clecrerse ol hallucinatory earphones through sr'rbiect the playcd to any of thc colditions il] which sou[cls werc of a 30treatnrent psyclroklgical tlrc (19[J7) reported (Nlargo ni., 1981). Morlcy
,",,r_l,r,r

Distraction by lne ans of music presentcd i. the frequency and clarity of by a portable cassctte pro.c.,l a trrnsient rccluction were totally abolished by the hallucinations. subsequently, these hallucinations co,siclered more effective than wts ,"ii,,,"r^f placement oi a wtx earplug: attcntion 'about a foot awtty from my right ,iiri.n.ti,,i. The patient locatecl thc halluci'ation car' right the in car', anl thc plug was only elfcctive

*.,, *ith ar-rclitoryirall*ci'al,ions.

irilpairecl

was l'ested by ersliing thc ability of rltc.rrtive r,cn,ri,rgi. 'Iolarania oJ' tunbiuit1 by u mashing noise o[ obscurcd was paticnt to rccognizc u spoL"ri *urci, which volumc until recogniin recluced gracluerlly was noise fcoplc reilcli.g.llr" *ori.ing o[ less familiar kuowlctlgc subjcct's the tests ricnrri,rg.s tion occr_rrrecl . Alt*tmtivt (resulting perception quality of worcls. Thcse two proccsses rcclucecl tlte

Sclrizoplrrcnicptrtientsexperiencingauclitor.ylrallucinatiorrswcrelblrncltobc avarilir cognitivc p.o..rrLg iu thc aspccts of tolerance o[ ambiguity and

ancl grandchildren that rftcrnoon. IIis wife saicl that this was rlot true; he ltird bccome vo:y alitatcd and distresscd ovcr 12 hours atrcl rro otte had visitctl thc Ilousc that da5r During intcrvicw hc was intenscly agitatccl ancl tttt ltis lrarlds in liolrt rr[' his facc. Ilc clairecl that he crould sec clearly sltcct ol glass hall it nctrc irt liortl ol hirlr which he atl.cmptecl to movc. Later he describcrl seeiug dust [alling clowtt cvct',tvhcrtr and was trying to catch it. IIc manifcsted clouding ol' consc:iottsl-tcss. A diagnosis ol' viral enccphalitis was made on the basis o[ tire history o[ pcrsistcnt headachc, thc neurological signs, and the Iinding of lymphocytosis in thc cercbrospinal fluici (Sirns and [verett, 1994, personll communication). It is often difficult to decide whether the full criteria [or the prcsct'tcc o[ au hallucination have been fullilled in the visual modality. Diskrrtion of visual pcrccpts, based on either sensation of external stimuli or internal interferencc with the visual pathway, may produce disturbances which are similar to those occurring with entirely new perceptions. Sometimes the account of his expcricncc given by thc patient sounds like ar sensory transformation rather thatt an hallucination, but thc bizrrre ad corplcx rrature oI the cxpcrience renclers pltcuomeuttttological dcscripQ

n?

tiorrrlitticult. Visual hallucinations occur with oct:itiLallobe iluttotu"s involviug the visual cot'tex, [or exirmple tuberculous granuloma in the left occipital lobc causcd I 'st.lrburst' effect in the right visual fielcl (Werring and Marsden, 1999). tlallucinatiot.rs
and other visual disturbances may occur wiih other physical lesiotls such as loss of' colrur visiort, honrcnmottshenanopia (loss of hrlf of the fielcl ol vision, the satlre hlf in both eyes, I(omel, 1985), dysleria (inability to read at a lcvel appropritc to the individual's age and intelligence) and lc;tia in a dominaut hcmisphere lesiou, anl corticnl blindness (blindness cluc to a lesion of the cortical visual centrc). llhey mty, aS in delirium tremens, be associated with an affect of terror, or with an affcct

,*u,ri,rg,.I

ilrlralltrcination)byintroducingcrrorsofpretnaturciuclgenrentwitlroutthesat'e-

(Hcilbrun ancl BIum' 1984)' g.,,,.,f oi s,-rbseq'-,cntly considerecl rltcrnirtives ' So,rr" auclitory hallucinations rre consiclered to be 'first rank sympto[rs of schizo-

heard nrguingT with eacl'r plrrcnia' (Schneicler, t9 59); these are ndil.l th.ou.gltts, voic:s These thrce perceptual ,tlrcr, antl ,oi,,., ,,,r,,,,1r., r'tinp on the patient's bchaviour" eitchrepresetlt r massivc interference tlistr,rrbances, as other lirst ranhsymptoms, is 'I' from what is 'not *irf, ,t,. bountlarics o[ scll'-iragc, the discriminatiol o[ what

1'(Sims, 1991). patients to copc wilh pcrsistent The ,rcchanisms trsccl by chr:onic schizophrcnic andTalbot (1981). The strategics auitury hallucinations wcrc rliscusserl by talloon

usccltocopewithintrusivcvoiccscoulclbeclassifieclrschangcsinbehaviour,in in behaviour included alteration scnsory/aflbctive statc, ancl in cog[itiofl. changes

;,f

hallucinations also occur in thc moocl poslcolrc:rrssio nal state, in tpileptit: twiliglrt sntcs arld in metabolic disturlances, Ibr cxamplc hcltat.ic lailu"e. Visual hallucinations havc also bccn dcscribctl itl tssociatiol with various demcnting processes includir-rg Alzhciruttr's cliscirsc (lltrrus cf al., 1990), scnile deurcntia (Flacldad urd Benbow, 1992), nrulti-itrlttrct dctncrrtiit (Cunrmings ct al., 1,987), Piclt's cliscase (lly, 1973) and lluntigton's cirorc occur in other lurms o[ delirium.
Visurl

o[ hilarious absurdity. similar visual hallucinations, illusions ad

changes in

L'hysiological lying clown or seeking out the company of others' or physical exerrelaxation through hallucinrtions with cpe to arousal wrs irlterccl control of atte[tion or active supcise suchas jogging. cognitive methocls includcd the common sense application that pressio, of haliricinatiols. Thcse authors believc

;;;;.,.",

such

ts

(Lishman, 1989). Amongst refcrrals to a psychogcriatric servicc visual percepl.ual disturbance occurrcd in 30 per ccnt of patients; there wrs a strotrg co'clrtion between the presence of visual hallucinatiofl and eye pathology (Bcffios at.rd Brook, 1984). In [act, visual ha]lucinations are corlmon in cldcrly patients with a wide variety of medical conditions and often no psychiatric history (Barodarnala
and Mulley, 1997).

otstrategiesusedbypatientscatrbebeneficialinthecotrtrolofthesedistressing
sytlptoms.

Visual Hallucination
staftrs rathet: than in tl're Visrral hallucinatio's cirarrctcrist.ically occur in oratic to the clull' psycllrct'errccl wls matl (r9-ycar-olc[ rnarriccl fnnclional psychoses. A Hc sakl that his lil'e was rt irn encl iaLrist in a casuity dcpartrnent for asscssmenl.. by his daughter-iu-larv anrl hc descrved to ctic as he hacl bcen caught tuasturbaling

I-Iallucinatiols have also becn described by individurls aflcr snilliug gh-rc and pctrol. Thc drugs mescalin and LSD are potcnt causcs o[ visual pcrceptuarl chetrrgc. Visual hallucinations are infinitely variable in thcir contcnt. Thcy range fi'om cluitc crurlely lbrmed llashcs o[ light or colour (elcmentary hallucinirtions), through trjorc orgauizci pattcrns and shapcs, to complex, lirll, visqal per:ceptions o[ pcoplc ad sccucs. Visual and auclitory hallucinations may o(:cL.r syttchrouously in oL'titrric stat,es, lbr examplc irrtcuttoralloltc cpilttltsy a'risual hallr"rcilration o[ a huntan ligr,trc
was rlso hcard kr speak.

t03

l02

SYMPTOMS IN THE MIND

PATI]OLOGY OF PEITCIPTION

psychornimctic clrr.rgs thcre arc altcrittious ill spatial perccptiorl, in the and pcrccptioir of movemcnt, in thc apprcciatio[ of colour, and visual illusions drugs, similar and LSD with occur Ilso hallucinat.ions may occur. Syrtarrsfhcsirrc in although only rarely (Anclcrson afld Rawnslcy, 19 54), that is a sensory stimulus subiect mcscalin orre modality. anothcr iu as a scnsation pcrccivcd is one rno<.lality

with

n-rodiliable lry voluntary control, for cxample closing thc cyclids, iulcl lllt:rc is usually insight conccrning tl-rcir 'unrcality'.'lihis is sornetirnes associrt.cd with lcar of rncrutal illness and would suggcst that these phenomena may bc pscudohallucinatious

rathcr thrn 'truc' hallncinations in sornc

cases.

'[clt, srw, tastecl and smelt thc utlise o[ the trumpet" (although somc o[ Visua[ hallucinations al'c very ullcolnmon in sctrizophrenia abnormalil'ies that visual othcr [br 'hallucination' tlle carlicr writcrs used thc tern 'rnornrlous pcrceptual to refcr (1991) caut,iously cutting and occurrccl). Pcrsirucl the expcrienccs in the visual ruodality' in schizophrenic patients as, for example, Thcse distorted' to be p,,tic,tt who although still recognizing it fitce c<lnsiders it always autllors rctorl. lbur such cases o[ perccptual clisiulbrncc in onc visual licld, aft'ccuncotnplicatcd iu occur to rcckoned not arc thc lcll ticrlil. Visual halluciuations autlitory patient clcscribe to thc lbr ilr schiztlrhrcrlia is cornnron tivt: psychoscs. It the pftouernes lrrllucirrations associatecl with visual psctulolruIlucirtatiorls' Although a normal pcrol arc cclmpletc, uDcl appear to have all thc characteristics, subjectively, hallucinaauditory the of basis ccpt, thc visual expcrienccs are oftcn inferred on the how instances' in tnost to see, possible is It tios tnd of conteurporallcous clclusions. experiences' visual of the content the for accounts fanl.asy psychoticalty clisordcred sccuic halluciuatiorls havc bccu described it otteiroitl states of Viui,l
sc:hizophr:enia.

Delirium tremens
The alcoholic withdrawal syndrotne of dcliritutt trettrcns is a specific form of acutc organic syndrornc, and is characterized by gross changes in perccption, moocl antl conscious state (sce Chapter 3). Pareidolic or affective illusions are oltcn prodromal in clclirium tremcns, and these are followccl by visual and haptic Lilliputitut hallucinations, which alc often of little arimals or diminutivc men. There is a lizarre intcr'rningling o[ ffcct. so thrl, thc paticn{ expcrienccs starh tcrror rnd, at thc samc tirrrr, a surI oI criizy comicah-ress cspccially collllnon with t.hcse tlisordcrs. 'I'hr: hrllucirrrl.ions in delirium tremens rnay change so rapirtly thaI thr: paticrrt iras clifliculty in describing them. A patient crxpericucing such visurl phcuonrena tried to portray this in F'igurc 7.3, illusions arc fiequcntly rssociatccl with hallucinations, espccially affective illusions, in which, through thc preclominiurt mood statc of terror, cracks in thc wall o[ the warcl, or curtains moving in the breeze may bc misinterpreted in a frightening way. At the same timc such patients are irighly suggestible ancl can form abnormal visual experiences as a result of suggcstion.

other somcti[rcs visual hallucinations do not. appcar to bc rssociated with any is a irnages) (phantom visual synclromc psychiatric trbnorrnality. Thc charles llonnct associin hallucinations visual cotnplcx cxpericnce .oiraitiun in which indivicluals psychopatl-roklgy or disturbatrcc ol at,ir.n with impairctl visiorl without demonstrable

"lubo.ute In these states thcre

is also an altered state of consciousncss.

ill t'he normal consciousncss (schultz and Mclzack, 1991). Although more cornmon pcripheral or with cenl"ral elclcrly, it can occnr rt any agc aud is usually associated pcoplc, anircduction in vision. Ijpisodcs rnay last liom days to years with irnages o[ static' bcing imagcs the reported, frcqucntly rnost bcing rurals, buildings trncl scencry in the importance is of co'clition this Clcarly aniratcd. ficld, or thJvisual ,.,r,,uirrg i,

cli[[crential dia gnosis. in the dcaf In rnost cascs ol charlcs Bonrtet syndrourc, and in musical hallucinosis (Fuchs ancl pathology brain no clcmonstrable is to which it has bccn lihcnecl, thcrc ct al' Ibcloll by considercd bccn hrvc synrlromc this o[ lcaturcs l,autcr, 1992).'Ihc
(

l99O) to bc as follows

I 2

nonc ()l ttrc lbllowing aro prcsclrt: tlclirium, dcmentia, orgatric affectivc or wil"h tlclusionrl sy[dromcs, tsychosis, intoxicatirlrl or ncurological clisorclcr lcsiotls of t.he cctltl:itl visurl c:ortex 3 therc is recluccd visiorr lcsultillg lionr cyc tliscitsc iu most cascs.

clclerly persous with nonnal consciousness expcrience visual hallucinations

1. . q

\i^"

Figure

7.3

The experience of deliriunl tremens

usually llalluciuations in tllis co[clition arc ttlways Iocatccl irt cxtcrnrl space' ill:c vision pirticnt's impaired l.he than tlistinct and vivid colourcrl, and arc uruclt lnorc <-nc third of cascs' such about' il1 rlt'trtcrlfurrli is cotltcttt pcrrnit.'lhe woulI othcrwise human figurcs, as photisms or gcornctric patterns. Complcx obiects arc most often be liagrnentecl may lcss ollcn animals, plants a[cl inanimutc objects; Lhcse objccts pcrcepts may bc Thc room. tho gli<ling through and may change ovcr tirnc - Iigurcs
104

Autoscopic holluci nation

s<-r rnany Lopics o[ consicicrablc phcrnonrcrurlogical intcrcst, Lhc tr:tnr iltttos(oltll has bccn uscd with cliflcrcnt rncanings and definitions sirtcc ils lirsl ttsc by lrr in 1u91. Thc cxpcricncc conccms how thc individual rcgarcls thc bouudarics ol sell' ancl is discussed lurther with other disorders ol sclf-irnagc. lt is bcrst to rescl:ve aul.oscopy fbr abnormalit.ies of visual perccptiou involving, .sccirrgi crrrrsc//;

l,ilic

r05

sYMPTOMS IN THE MIND

PAI'HOLOGY OF PERCEP TION

vist:eral hallucinatio,s are ftrlsc perccptions o[ l.hc inncr organs. 1,hcrc is onry a limited rangc o[ possiblc viscct'al sensation, lor examrlc pain, caviucss, slrckri.g or tlistensiou, palpitation and various combinrtions of thcsc snch as tlrr,bSirrg. I[owcvcr, thc possible raugcrll'bizarrc schizoplrrcnic
ationo- is lirnitlcss.

'visuul cxpcricnces where subjccts scc an imirgc ol' thcmselvcs in extcrnal space vicwrcl [r'oru within thcir own plrysical body' (Dening and l]crrkrs, 1994). Although this topic hs bccn ol'considerable literary intcrcst over the years, clin-

witll tlcfinitc pclccptual abnorruirlity rrc not conunon. Dcning urd Berri.rs llavc rcvicwcrl 5(r cascs, 5] [i'om tbc Iil.crrture and 3 of their own. Malcs prcdorninrlr:tl with a ratio o[ 2: [, urd (hc nrcau agc o[ subjects was 40 years, I]oth neul:ological aucl psychiatr:ic disordcr occurred in about 60 per cent of cascs (diffcrent sub.iccts), with epilepsy in arpr<lxiurately one third. Decreased consciousness occurrctl in 4 5 per ccut, dcliriurn in I ll pcr ccnt, aud 9 per cent ol sub.iects wcrc dcad within I year. Visual imagery or nrrcissism wls pfesenl in one third of subjects and dcpcrsonalization in I8 per ceut.'Ihe comlnonest psychiatric diagnosis was depressiorr. Usually autoscopic cpisodcs lasted tbr less than 30 urinutes, almost always the subjcct saw his own [lce, quite ollen he wrs lying in bed at the timc; the experience oftcn provohccl distrcss, fca anxiety and depression. This subjective experience was complcx, with diffcrcnt compouetrts und causes, rather than unitary.
icalcrscs

Hallucination of Bodly Sensation

It hirs bccn convincingly ar:gucd by llcrrios (,1 9lt2) ttr:rI tlivctsc 'rcrcertions without objcct'werc bror"rghl togcthcr by lisquirol (1ti17) within thc tcnn /lnlluciruriort, which was rclcvanl lirr 'clistaucc scnscs' sttch as visiot-r, hcaring, ancl, [o a lesser cxtcnt, srnoll and tastc, bul not rcally applicablc to touch. So-callcd LaL:Lile lnllru:inntiorrs irppcnr ti bc cliffcrcnt phcnomencllogically alld only superlicially resemblc hallucinatious o[ thc distance scnscs. II woulcl sccrn for tactilc hallucinations thal the rnost irnportant corroborating diagnostic l'rctor is the concurrence of a delusional component. Prcrrios concludcs that thc concepts of hallucination and delusion nrtry be ckser to cach other than has oftcn been considered, especially in British psychiatry, Ilalluoinations o[ b<xlily scnsation may bc sux'rfrcinl, kitrucsthetic or viscnl. Srrpcrlicial hallucinations afl'ccting skin sensation rnay bc tlrc.ntL, an abnormal pcrccpt,iorr o[ hcat antl colcl -'my fcet on lirc'; halttit, ol Louch - 'a deacl hand touchecl nrc';<rr lryric,ir pcrccp[iorr ol'Iluid-'all nry bkrocl has droppcd into r.ny lcgs ancl I can l'ccl a watcr lcvel iu rny chest'. Panrcstltasiue is thc tcnn tlcscribing tlrc scnsrtion o[ l"ingling or 'pirls ancl nccdles'. 'I'hese mity bc delusionally ascribcd, alt.hough of r:oursc thcy rrc oltcn ucurologically lneciiatcd, for cxamplc rilnrr ncrve comprcssion causing pins and nccdlcs in the fbrearm. I{ilmcstltctit: hallucinations arc thosc of rnuscle ol joint scnsc. Thc patient fcels that his lirnbs arc bcing bent or twistcd, or his muscles squcezed. Such hallucinations in schizophrenia arc oftcn linkccl with bizarre somatic delusions. A mrn su[fcring fiorn schizophrenia described the experiencc thus 'I thought my life was outside my fcct and made them vibrate', he cxpcricnced liinaesthetic hallucinations o[ vibration. I(inaesthctic hallucinations nlay occur in organic states: 'a feeling ol bcirrg rocked about'. Abnormal kinaosthetic perccptions have also been described in thc withdrawal statc l}om bcnzodirzcpinc drugs (Schopf, 1983), or from alcohol intoxication. A man, afl,er rccovery, describcd his episode of delirium tremens saying 'l lelt as il' I was fioaiing in the air aboul. lilty feet above thc ground'. [Ic illustratcd this t'ecling with thc picturc in Figure 7.3.
106

t<"nnc,ly brothers all the ti.re', It is importa't to realize that there is bth a hallucrinrkrry a,cr delusional componcnt in such experiences. onc particularry unpleasa,t form or. haptic lrallucinatiou is callcd fortnicaliort (Latin, forn rica - ant), thc sensation ol liltlcr animals or insec[s crawring ovcr the bocry or iust unrrer trre ski,, lfrris is cspccialty associalcd wilh some drr,rg states and wil"hdr:awal sl,rnptont5, tt,,, atldicliorr antl illcohol withclrawal. lt is ottcn associalcd "*,,n,rt.".o,,ui,,. witir r[,1r.sir.r.r o]: itr.fL,stnti<ur, but l.he lal.t,er may <-rccur without hallucination.

lnlse perccplious ancl i,l.crprctonc nlttt belicvetl that he could I'ccl scmcl travctti rf ,f ii, ,..r,,bral colum, i,to his brai, whc.c it bcciu,c raicl our. ill shccts. Ilallucit-rations of bodily setlsttiotr arc quitc conlnloll il schizolreiir rncl arc alnrost always delusionally claboratccl, oltcn rftrlrsiorrs o.l' L:orrt-rol(chartcrs [g a,d 9). Haptic hallucinations nay be experiencccl as r.ouch iriL" u rrora ,t,-ot i,rg ,re,; or painful - 'knives stabbing my neck'. A patient believed that the smokc sensor in thcr ward was an infra-red camera 'becausc I feel it wrrnl on ,ry ,ccr<,. A.othcr patie,t described a htrptic hallucination in which she experienced genital stimulation which she ascribed to having sexuar rtercourse simurta,eously with ,boti,

Olfactory and Gustatory Hallucination

lallucinations o[ srncll ancl of taste frcquently occur togcther ancl it nray bcr tlil1icult or impossiblc to distinguish thcrn from each cithcr. Thii is not ,urp.iri,a ,o a lot of. what a lay pcrson ascribes f.o taste is actuaily s,re[ ,thc cucalyptu, ti.,,g,.,,,r.. nt, this winc frorn the Barossa Vallo,'.
O lfo cto ry h oll u ci n oti o n s ollactory seusation or memory is ofl.cn associatecl with power:tul crnotioual res,r.rauccs (Lhcrmitte, 1951), it is not sut'prising thercforc that allucinrti.ns

quite common in schizophrenia ancl related paranoid statcs. olfactory hallucinations occur in cpilepsy, especialy in assr.ciation witrr a tem_ poral lobe focus, and commonry forn thc aura (or earriest phase) of such ts, A pal,icnt dcscribed a smell o[ bur:ning rubber r:egularly j,st bctore h. t ..u,,,. u.r.nr_ scious, Vistal, auditory, gustatory and visceral hallucinal.ions alst rccur in lcrnprral lobc cpilepsy,

with thc bclicf that pcopre arc pumping a poisonous or a,aestrretic gas i,to .hc house which the paticnt arone can smelr. sometimcs patients rrave ,rir oil.ctory halluci,atio, relating to.themserves: 'I smerr repulsive, u,bearabre * rike a corpse, like faeccs'. This particular patient killcd himself. He felt that he created such r stench that he was intolcrable in any reasonable society. sometirnes patients misi'r_ terpret and ottervabrc normal body odours. A cielusion in which a patrent believes himself to smell malodorously without an rccompanying olfactory haliuci,ation is
ated

are als< invcstcd witl-r a strong affcctive component. olfactory halluciatios occur in schizoplrr:cnia, epilcpsy and in some otlter orrtir: states.'I'hc paticnt has an hallucinrtion o[ srncll' Thc srncrr may or may r.rot bc unpreasa,t, b*f it usually t,r., o ,p..iut o,,a pcrsorral sigr.rifica,cc (Aggc,racs' quatity o[ rc]cvanL.a),fo. exu,rplc

it uray bc associ_

t07

?ff;i lE f i'^if il?ttiiE i i li * i; i ;r= ; iiii?r-uiz;*"=ir = =; = * =* =?*?=7 H EE"= l=i=laE=+ =72riz*: f 7-v7illi$ e rilir=lF ;r z==3i i i + iEiir
1==i==1iE='ri1?78*i?ue +-== :1r- F rE=^?t=-:onrz*lri [=.
c

I
i

5 i=iEi ri iEL1;;1iiEi;r;iisalEi=* E+if $ i1? ll; =siEir,"!liir;i;21f=fia;; ;;=u.Eri +;ifirlii-l-=liE== ; v=ig-!is

EgfE i

q f 'f :iii 11li.7?z-Ecei+ +Eg

?E!=Z=3ii;ii;;?;ilii;illi iti?=: i;riE L;i;+=,;i*g gi! r

i=

r+s: =

liiii

iE+1!li11.+ir;??fi:sa* srEs +=E:trl EE;i t=i=E1i=1rirllri+31 r'aiE ;rlA +5=Es: E=iii=:==1=eE:;=?i=E ; i i=3: gi; ! =f5.F ia+ l=i iglrl i i ri; ;; 1i=:.qF;;=,iiEEi 3l;u
s

iiri iiE ilgrllilil as.=Be.Br?srB+-a *l;?+= i.+

Table 7'

=E

?=.=-7i;

i;i
and

i FE iFEt riEii ;xl;

The nature of pseudohallucinations (panly derived from Jaspers 1962

from Aggernaes I 972)

Perception

= Hallucination I Experience 2 Location in 3 Definition

p..rdo_h.llu@
is concrete, tangible, obiective,

a
k

real

'inner

eye'-)

pi.ao.irt

,ruu.,i*

outer obiective

space sound

_> <_ t_ <__ <_-+ -+ _+ (_ -

n
\-:J

inner subjective space indefinite, incomplete only individual

details

definite outlines, complete

>

Vividness 5 Constancy
4 6 7
lndependence from

brght retained
full, fresh,

most elements are dim or neutral

evanescenr requres voluntary creation

?,

volition

cannot be dismissed, recalled

changed at will

or

lnsight

has quality of perception _ no distinction made between perception

fantasy has qualiry of idea

-E

and hallucinations

relevance 9 SensorT modality

Behavioural

rerevant to emotions, needs,

could experience object

modaliqy
l0 Existence
I

actions in another

not rerevant

could not experience this obfect in another modality

obiectexistsindependentofobserver

dependsonobseryerforexistence

I r o o o n
-E

-{

Known to be dependent on 'my abnormal state'

independent

v
r^^-f,^^dependent

fTt

o rO

-J

SYMP'IOMS IN I HE MINt)

t'AIHOLOGY Ot. ptiltcEpt tON

lJrosc associrted witrr srccpiug trnd wakirrg, pat.rrorogi<:al, pscurrorrirlluci,rr.i.rs occur in peoplc without ntetrltl ilhrcss at tinrcs oI lit'c r:risis. Ir.r: r:xirrrrrlc

talking about tllc paticnt itt a tlerogutory lashiou (this was dcscribcrl as /rcnrl in thc tusuitl way - thus, hallucination) urcl srt to bc 'lcering and sucering' (not clcscribecl as a tturnlal perccpt - pscudr-rhallucination). Part o[ lhe confusion over thc nrcuning o[ thc ternr pseuclohallucination has arisctr bccruse it is usecl in two clilTercnt and mutually contladictory warys according to I(riiupl Taylor (1981). It has bccn uscd to rel'er to sclf-recognized hallucinations (eitherexteroceptcdorintrocepted) (IIare. lL)73),ortointrospecteclimtrgesof great viviclttcss - thc vicw hcld by l(andinshy and, latcr, faspcrs. Iftupl Taylor quotes
Itrs;crs'It is a fact that one crnnot havc cxperienccs in both pcrceptual ancl imaginecl spilccs at the sarnc tirne. There is no transition [rom one spnce view to thc other, only a iunlp'. 'l'hus, the lal.tcr woulcl corrsicler pscudohallucinatious, despite thcir vivitlucss, as bciug ull"irnatcly l variant o[ fantasy and thercfore no[ carrying the cliirgrroslic inrplications o[ [rlrc hallucinatiorts.'l]he clilficulty ariscs in thc pal"icnt's own obscrvations upon his expericnce: he uray wrongly ascribe internrl cxpcricnce to oul,side reality ber:ause the rhcnonrerlorl is obl.rusive, unclcsirecl ancl vivid. Whcn I'rc is rclying on nlcmory to dcscribe the cxpcricncc, what was actually iruagined may bc juclgcd us having bccn perccivcd. For thesc reasons it is rnistakcnly thought thal" thcre arc tr'rnsitional stages bctween pseudohallucinations and true hallucination. In this booh pseuclohallucination is rssumcd to havc meaning in the traditiou ol
I(anclinsky, faspcrs ancl Aggeruacs. IIarc (1973) has givcn as an exatnple of pseudohallucination the voice heard by an obsessionrl cr clcprcssecl person. It is described by the patient as a voicc, but is actrrully recognized as his own thoughts. Pscudohallucinations arc not pathognoronic of any particular nlental illncss. A raticnt with histrionic personality clisorder srw a robcrl ligure at thc foot of her bcd lif'ting his inclcx Iingcr to his mouth to caution l-rcr to silencc. The irnage was sharp and vivid but wrs rec<lgnized as being seen with l"he inner eye. Thc patient hnew that thc figure was not at the foot of the bcd and that other pcoplc in the room could not sce him. \A/hen she tricd to relate the figure in sptrcc to the backgrourld of her fielcl of vision, in this casc the walls and curtains of thc room, she rcalized that shc coukl not do so, it hrcl no dcfinite locati<n in outer spacc, that is outside hersclf. A lhrthcr exarnplc rf pseudohallucination was lhe experience of a man agcd 31 who was 'clcrressed' following his wifc's death in Australia. Hc wished to rcturn to Australir rncl so stowecl away on a ship, but thcn he leapt into thc sea and was discovcrecl 'Nothing coulcl stop lnr: rcmernbering my wife that night. I belicvecl I could sce her in the water bcckoning to me. So certain was I that I got two lifebelts and dived into Ihc sca. I begau to sea:ch for rny wife. Thc water wrs ice cokl and I saw the ligtrt of thc ship rlisappcaring.' Aftcr 10 hours in thc sca he wrs rescuccl, Orrc could argr,rc that his bolict was delusi<nal, a sccouclar, delusion pr:ccipitatcd by dcprcssivc mot-d. Ikrwcver, thc perccption was vivicl and corrrpclling, unlikc farr[irsy. Il was rcgarcled as bcing di[f'crcnt froln a normrl percepl.ion in its emotional concorrritants and, t.hcrelilrc, also tlillcrcnt li'otn ur hlucination. Although actcd on it was in somc way symbolic: hc wrs urrhappy and wantcd to clie lather than actually bclicving his wifc was alivc ancl well and living in the sca!

psc,dohallucinat.ions of' bcrcavcmcnt arc wcl recog*izocl trnc[ a parr_icurirrry drirmatic oue ltrs bccn tlcscribccl abovc. Iu morc usual circurnstances tlrc witlow hcrr.s hcr dcccasccl husbrnd's voice; she hcrrs tlle chrrrctcristic thump o['his boots orr tllc [loor as she prcpares lbr bccr; shc sces him in his armcrrair sciapi,g rris pipc; sht: thinks she saw hirn walr<i,g arong the strcet and roorri,g rnto trr.ii",r*gc,rt,s wi,r_ dow 'with his characteristic quizzical Iook'. Thesc experiencer^ huve bce psychopath,logical stantl_ point and rcciron therl usually to be pscudohallucinations. Ncarly half ol'a population of wiciows nd wi<lowcrs lrtn nlid-Wrk:s iu(crvicwcrl . by Rccs (1'971) werc louncl to havc abuonnal pcrccptrral expcrr:icnccs rclalirrg to tc dcatl sponsc witl'ri, the l'irst l0 yc.rs o[ wrcluwhoo,l. t]nlcss lhc ri.u,,l, ,,u,litory r. tilctilc expcriclrcc, or thc scnse of prcscncc cl thc clcacl spousc rvas rnrrsitlcrcrl r"r,rrl it
trke issuc

ItalluL'ittntiotts oJ ruitlowltootl, but

I woulcl

clcsc:ibc as

[ro.r

pathological.

thcir fonn would suggest pseudohallucina[ion. 'Ib sumtuarize, the sigrlificancc ol hallucination is that it almost alwarys cterotcs morbid tlental statc. The signi{icance oI pscudohallucination is i, its clifferential diagnosis fronr hrllucinatio' as pseucloh'lluci,ation is not ucccssurily psycho-

ject as rcassuring and hctpl'ul rather than clisturbing. It rvas unusual [or.thcsc expcriences to have becn cliscloscd, evcn to close frie.ds or rclatives. rtrc a..rcrti,r,, ot.

was cxcludcd [ro[r the ntttnbcr, drcuns ol' the spouse ,verc also cxclut]c. IIe lookcrtl at thc cit'cumstances it-l which thcsc perccptions occtrrrcrl rnrl lounci thcnr to bc ruolt charrctcristic o[ normrr, stable pcorle orrrighcr social class, especiall, arlcr a long ar.rd happy rnarriagc and parcnlrroocl.'r'hcy i,vcrc gcncrally .rpoi",r..t by tlrc sub_

Other Abnormalities of perception

Autoscopy
of scaing oneself ancl k.owing that it is oncself (see also visual hallucination, p. 102). It is sometimes callecl the plmtorurttirror irtrar:.rt,is one of the abnormrlities of unity of sclf described in chaptcr r , but ir rrrrios'l thc experience is ,ecessarily visual. Autoscopy may take the [o,, of a pseuclohallucinatio,, for instance l person sees himserf distinctly and vivicy, thc i,rage rasts rbr somc timc and did not seem to be conjurecl up voruntarily, the pheno,reon is con_ sidered to be in the subject's 'mind's .oth.. tha, in precisely locatecl
exte.ral
Autoscopy is the expericn ce

"y.' such pseuclohillu.i,otiorrs, spacc. schizophrc'ic patic,ts may havc trui it ul, occurs in orgtrnic sr.ates such as tcmporal lobc cpilepsy ancl :ar-ict.al Iotrc lesio.-. o, occasicns autoscolty rnay tal<c thc lbu ol truc visual halluciurtiurn; tiris is likcly to bc associatcd with rn organic state.
ab,ormalitics ol' body i,ragc o[ pcrccptuar l]lr.urc occur. ia orga,ic states in which thc pcrsoll may sec hi,rself or part of rri,rseil replicatetr. Autoscopy is quite di[fcrent fro,r the cnpgras sgndrotru,, which is not a, abnormality o[ i]crccp_ tion at all but a delusional miside,tification ol' a person pcople or close to the iaticnt. lvuil" nutosl'oPlJ has also been dcscribed in which, lbr insialce, tne paiiet loolts
r"tlc

various

l'scudohallucination is pcrhaps thc rnost likcly phcnomcnonok)gical forrr to tlcscribc thc apocerlyptic cxpcricncc of uisions, although, of coursc, these rnay also occur in dreams and as vivid irnagcry, Unlikc hallucinations which are, apart from

'r\

,\

lllu.ror alld sces no image at itll.

i.

ilo

ilt

SYMPTOMS IN THE MIND

PATHOLOGY OF PERCEPTION

Extracampine Hallucination (Concrete Awareness)

'I kuow that there is somcone bchind mc on thc right all the time; he movcs whcn I urovc', 'I hcep on hoarittg thern talking about my discase down in the post officc' (halI a ntilc away), thesc halluciuations are expericnccd outside the limits of the sellsory [icld, ouLsitlc thc visual ficld or bcyond thc rangc of audibility.'lhey arc not of cliagnostic irnportancc rs thcy occur in schizophrcnia, epilcpsy, other organic statcs anrl also rs lrypnpit' Inllrrcinrlions in hcalthy pcople.'lhc phcnomcrron is quitc rlefinitcly expcricnccd as a pcrceptiou by thc paticnt, ancl,not just as a bclicl
or irlca.

Reflex Hallucination
As a doctor was writing in his case notes during his intervicw o[ a I'cmale patiet, se said 'l can feel you writing in my stornach.'The patient saw and heard the act o[ writing aud was quitc surc that it accounted lbr thc tactile scnsal.iou in lrcr abdomcn. A stimulus in one sensory mociality producing au hallucination in rnothcL'is callccl a ru,/k** hlh'intttiott. T'his is, in f'trct, au hirllucinalory forr o[ s/rtrrc.s/tc.rirr, rnentioncd earlicr as thc cxpericncc of a stirnr-rlus iuragc irr orrc scnse lr.rodalitl' rroclucing an imitgc in auother, for cxamplc thc leclirrg of' tlisconllirr.t ctused by seeiug and hcaring somcbody scra{.ch a blacirboard wil.h their Iigcririls. Anothcr rcllcx hallucinatiott occurrcd in a wolnan who cxrcricnr:cr[ pain wccvcr certlin words were mcntioned. Functional ancl rellex halluciuations arc not l.lurmselves of great diagnostic or theorctical signilicancc, but tl'rcy requirc rcrrtioig lbr completcness, and recognition in order to identify other rrore irnpgrtaut sylrptoln^

Hypnagogic and Hypnopompc Hallucination

'I'hcsc are pcrceptions that occur whilst going to sleep (h11naogic\, and on walrirrg (hyprropottrl:it:). Accor:ding to Zilboorg and IIenry (1941), hypnagogic hallucinations werc first rncntioned by Aristotle. It is known thal. the conscious lcvcl lluctuatcs cousiderably in diffcrent stages o[ slecp, and both types oI abnormal rcrception probably occur in a phasc of increasing drowsiness: the structurc of tlrought, fcclings, perccptions and fantasics and, ultimately, sclf-awarcness, bccomcs blurred and mcrgcd into oblivion. Thcse cxpericrccs occur iu many rcorlc in goocl l-rcalth.'I'hcy arc also describecl with rtrrt't:olcpsy, t:utaplaxy and slee4 rurrrllsis to lbrm a chrractcristic tctratl of symptoms (sec p. 58 for clescriptions). 'lirrir' stafs, fbr cxanrple gluc-snil'ling, acute lbvcrs (espccially in chiltlrerr), postiul'ectivc rlcprcssirrr, stafcs ancl phobic anxiety ncuroscs rrc o[hcr couditions Lhat.
rnay bc associatcd. '['lre pcrccption nray bc visual, auclitory or [actile. It is suddcu in occurrcncc and thc subject believes that it. woke hirn up, fcrr example a loud voice in the st,rect bclow saying 'world wrrl', r feeling o[ somcol'lc pushing hitn over the bed, or seeing u man conriug across thc bcdro<m. The irnportance o[ these phenotnener in psychopathokrgy is to rccognizc their naturc and rcalize that they arc not uecessarily abnorrnal, cvcn though l.hey may bc truly hallucinatory.

with c;nfidencc.

Abnormal lmagery
Some o[ the abnormalities o[ imagcry in which fantasy is admixcd in vurious 1rrceptual disturburces l'rave alrcady becn describccl. Sornetirncs therc is a lirilLrrc o[ thc capacity for imagery.'fhe paticnt may complain that hc caurot irirgie wftat f lrirrgs lo<k liltc - a clcprcssed paticut said that hc coulcl not rcrncmtrcr rruygc's lircc. Memory, in this contcxt, is subjcctivcllr thc sarre as fantasy. Wilh lirilurc o[ imagcl1,, although thc pcrsou cotuplaius thaL lte canntt crcatc tlrc ilrragc o[ 1 pcrrio hc l-r.ics to remcmbcr ctrough to enablc him to scc thc ltcrsorr in his ruillcl's cye, ltg is ablcr kr describc the cllaractcristics of lhe pcrson quil.c accuratcly. So thcrc is r lruc failrrrcr o[ memory and thc clcfect is in thc concomitant fcclings rssociatccl wit[ lutasy, rathcr than with the actuai ability to fantasize. Alongside the recognized symptoms of dclinitivc mentaI illnesscs, thcrc arc somct,imes bizarre cxperiences dcscribecl which may throw doubt on Lhe iliagnosis. A middlc-agcd man demonstrated symptoms of a depressive illncss, the dcprcssil wrs indisputable. Howevcr', he also described, on scvcral occrsions, secing yellow and green snakes inside his head, wriggling and attcmpting to clesccncl the rcrves. IIis intervicwers disagreed as to whether l"his was a cornplcx visual hallucirtio or rn cxercise in deiiberately rnisleading the doctor - neither was corrcct! As he improvecl on trertrnent, this visual expcriencc did not rccu lrut hc was quitc ablc to remcllr_ bcr it accuratcly ancl said that it had been associatccl with his fcelings oi guilt. Visual imagcry is more likely in people who dcscribc vivid imaginatiol and drcams prcrnorbidly, and also in those of morc histrir.nic pcrsonality. It is usually assclcirtccl

Functional Hallucination
'l'lris is thc sl.rangc rhcnourenon in which an cxtcrnal stimultts is neccssary to provolic hallucinrtion, but thc nornrirl pcrccption of the stilnulus and thc hallucination in Ilrc saulc nrodality arc cxpclicnccd sinrultancr-usly. A schizoplrrenic patient heard hallrrcinat<,rry voiccs only wheu water was runuing through the pipes o[ his ward. IIe lrcarcl no phoncrncs br urost o[ thc time, but whcn hc hcard water rushing through the pipes along thc wall, hc became vcry distrcssed by voices that told him to rlarnage himsclf. IIe wrs tcrriliccl of t.he contcnt of these voices bccruse he was ali'aid hc uright act tn thcm. IIc could rcadily scparatc the noise of water from the v<.iccs, urd tlre lattcr nevcr occurrcd apart liom thc fortner; but both perccptions wcrc rcc<lgrrizcd as tlistinct and r-rr1. Anrther patient hcard voiccs when the radio or telcvision was switched ou, alongside thc broadcast voices; hc had persecutory delusions that thcse acrtivi{.ies were carriecl out delibcrately to upsct hinr aucl he becamc vcry rlistrcsscd, and at timcs violcnt., as a result.

ordinary experience.

with the eurotional pcaks and trougtrs rather ttian thc hunlclruur platcaux o[

Sensory Deprivation
Continuing perception is necessary l'or consciousncss. The flcld ol' scusrl.ion varics Lhc outr;ide workl and Ii'om insidc oneself cotnpete for attention. Con.sciousrss consists of the intcgra-

all the time as individual scnsations iu diffcrent nloclalitics liom

tion o[' this ciranging field to form a

conrrositc awareness

o[ onescll in

ore's

tl2

il3

SYMPTOMS IN THE MIND

HOLOGY OF PERCEPTION

cuvironlllclll.. Thc csscutial ttaturc o[ sensation has bcen extrllorcd by studyi[g its

rbsenccasrevcrlcdbyrcscarchont.hecffcctsof scnsorycleprivation(Zubcli, 1969)' ll'his topic is only given bricf rnenl.ion as it is sgmcwhat peripheral to psychiatry, Sesory c[:privation was studied usiflg Ca[aililn col]ege studc[ts as volunteers (tlcxton ct al., L()54).1ihc subjects lay on a bccl wearing gloves with cardboard cull's utd trausluccnt gogglcs in a tight, but partialiy soultdproof room, there wls r continual background noise. This experiencc was lbund to be extremely urplcasant ard, clcspite being piricl, sbiects wcre not prcparecl to remain in this statc lor more than
3 clays.

do not. [hcmselvcs change, the observer will move his point of obscrvation in order to crcrtc chaugc.

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This techique has bcen refined subsequently to blot out external sensations nlore completely. Various perccptual abnormalities are experienced. Visual hallucinations of varying complexity were describecl, but further study of these perceptual changes resultecl in their bcing considered, more cautiously, to be 'reported visual sensrtions' and 'reported auditory sensations' (Zuchermann, 1969). These were classiliecl into'mcaningless sinsations' and'meaningtul integrated scnsations'. Sonle of the lattcr aIe ll1ore lilic hailucinatory cxperiences. Depending on the colnpletcness of {eprivation o[ other sensations, abnormal perccption occurs in r.noclalthan vision. Subjects show an alterecl affectivc statc: t.hoy bcco[re panicky, rcstless, irritable, or alternatively, borecl ancl apathetic. Dcspite considerable ncuropsychological resclrch with valuable Iindings fbr ipvestigating the scnsory environment in growth and dcvelopment, cleveloping brain interconncctions, neurochemistry 1nd neurophysiology, the study of sensory cleprivation hrs not so far macle as big an impact on descriptive psychopathology as was initially expected. Thcre are vrrious ditficulties to be accounted for: what part of the ellects of deprivation are due to failure of development and what to loss of behaviours already establishecl? How can olle usc rnirnal worl( to explore subjective sympit.ies ol.her

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6-Sl.

il4

r5