Hallucinations in The Psychothic State Psychoanalysis and Neurosciences Compared

Int J Psychoanal (2014) doi: 10.1111/1745-8315.
12239
Hallucinations in the psychotic state: Psychoanalysis

and the neurosciences compared
Franco De Masi*, Cesare Davalli, Gabriella Giustino and Andrea

Pergami
*Via Ramazzini 7, 20129 Milano, Italy franco.demasi@fastwebnet.it

Via Cenisio 45, 20154 Milano, Italy cdavalli@tiscali.it

Via Eschilo 8, 20145 Milano, Italy gabriella.giustino@fastwebnet.it

Via Carlo Poma 18, 20129 Milano, Italy andrea.pergami@libero.it
(Accepted for publication 1 May 2014)
In this contribution, which takes account of important findings in neuroscien-

tific as well as psychoanalytic research, the authors explore the meaning of
the deep-going distortions of psychic functioning occurring in hallucinatory
phenomena. Neuroscientific studies have established that hallucinations distort
the sense of reality owing to a complex alteration in the balance between top-
down and bottom-up brain circuits. The present authors postulate that halluci-
natory phenomena represent the outcome of a psychotics distorted use of the
mind over an extended period of time. In the hallucinatory state the psychotic
part of the personality uses the mind to generate auto-induced sensations and
to achieve a particular sort of regressive pleasure. In these cases, therefore,
the mind is not used as an organ of knowledge or as an instrument for foster-
ing relationships with others. The hallucinating psychotic decathects psychic
(relational) reality and withdraws into a personal, bodily, and sensory space
of his own. The opposing realities are not only external and internal but also
psychic and sensory. Visual hallucinations could thus be said to originate from
seeing with the eyes of the mind, and auditory hallucinations from hearing
with the minds ears. In these conditions, mental functioning is restricted,
cutting out the more mature functions, which are thus no longer able to assign
real meaning to the surrounding world and to the subjects psychic experience.
The findings of the neurosciences facilitate understanding of how, in the psy-
chotic hallucinatory process, the mind can modify the working of a somatic
organ such as the brain.
Keywords: hallucination, psychosis, psychic withdrawal, judgement of reality,

sensory phenomena, neuroimaging
The present contribution attempts to establish a parallel between the data

that can be inferred from clinical observations of patients in whom the psy-
chotic process has produced hallucinatory phenomena and neuroscientific
observations that, using objective experimental methods, deal with the same
phenomenon. It will also discuss the hypothesis that the hallucinatory state
derives from the patients construction of a withdrawal into a mentalsen-
sory condition dissociated from reality. Our hypothesis is that psychotic
hallucinations can be secondary to the development of a delusional system.
Therefore the hallucinations can support and confirm the delusion in the
patients eyes.
Copyright 2014 Institute of Psychoanalysis

2 F. De Masi, C. Davalli, G. Giustino and A. Pergami
Although hallucinations may affect all the senses (sight, hearing, touch,
smell, and taste), the most frequent, and those most commonly studied, are
auditory. We know that there is a yet unsolved problem of whether envi-
ronmental or biological components predominate in the generation of
psychosis. Our own approach is to consider psychosis as a biopsychological
transformative experience, a kind of illness in which the mind can be able
to bring about transformations in its biological substrate, the brain.
It must be stated at the outset that the relationship between psychoanalysis
and the neurosciences is highly complex, and that, for epistemological and
methodological reasons, the data accruing from the two disciplines cannot be
used other than in their specific, respective, and parallel fields of inquiry. In
particular, the neurosciences can identify the causes in the strict sense of the
word of behaviour, but can tell us little about the motivations of individuals
or the meaning of personal experiences (Talvitie and Ihanus, 2011).
Judgement of reality
An important aspect of the study of hallucinations is the judgement of reality.
How does a patient confer the character of reality on stimuli which, beyond
any reasonable doubt, originate in his own mind? It is typical of the hallucina-
tory state that the patient becomes unable to distinguish between internal and
external reality and loses the faculty of reality judgement. In hallucination, a
sensory stimulus from within is projected to the outside and assumes the char-
acter of reality although it does not correspond to any external object.
How can the mind be deceived by the hallucinatory phenomenon, and
what are the conditions that facilitate an accurate judgement of reality?
Some useful indications on this complex matter are given by Mark Blechner
(2005), who wonders how we can say whether something real has happened
or whether we have only imagined or dreamt it. This author quotes Kosslyn
(1994), who considers that, in the waking state, a subsystem that polarizes
attention on the stimulus to be perceived is activated. It is unclear whether
this is the same subsystem that causes us also to believe in the reality of
dreams and figments of the imagination. The judgement of reality is appar-
ently mediated by different subsystems in dreams and imagination: in
dreams recognized by the dreamer as such, the two subsystems are both
present and are compared.
Blechner reports the singular case of a psychoanalytic patient who dreamt
of his father, who had been dead for some time. The patient had often
imagined that his father might still be alive but, in the dream, he not only
appeared alive but was also young: on waking, the patient continued to per-
ceive the figure of his father as real. He was thoroughly convinced that the
fathers presence in the dream was authentic and real, whereas he was sure
that on other occasions when he had, while awake, thought of his father as
alive, this had been pure imagination. The patient therefore seemed to have
had a hallucination in his dream, as a result of which this perception was
experienced as real even in the waking state. Blechner believes that intense
emotions in particular, mourning can give rise to an alteration in the
attribution of reality, as when a widow hallucinates her lost husband. In his
Int J Psychoanal (2014) Copyright 2014 Institute of Psychoanalysis

Hallucinations in the psychotic state 3
view, this demonstrates that the attribution of reality is not only based on
perception of the external world but may, on the contrary, be a quality that
the brain can assign to a particular emotional experience.
The arbitrary nature of the judgement of reality and the dependence of
its alteration on brain structures that deceive the mind is demonstrated by
an elegant neuroscientific experiment (Schacter et al., 1996). An interviewer
read out aloud a list of names of objects to a number of subjects. The same
subjects subsequently read another, written list which included some of the
names from the first list (which had therefore been heard) and others in
which the objects in the first list were given different names, which, how-
ever, had the same meaning (for instance, sweet instead of candy).
Finally, the subjects were asked whether a particular word was or was not
included in the first list. Sometimes the subjects mixed up the names in the
second list with those in the first, whereas on other occasions they remem-
bered the names from the first list perfectly well.
Using neuroimaging techniques, the investigators observed that the
hippocampus was activated whether a subject remembered correctly or
incorrectly. The difference was that, in the case of accurate recall, the audi-
tory cortex, which is responsible for auditory memory, was also activated
(the first list had been read out aloud); conversely, when the memory did not
correspond to reality although the subject was convinced that it did, the
hippocampus was activated, but not the auditory cortex. The researchers
concluded that activation of the hippocampus furnished the conviction of
the reality of the memory, regardless of whether the memory was or was
not accurate. For the same reason, it is possible to be convinced of the
reality of a false memory of abuse that never actually happened (Pally,
1997).
Some psychoanalytic hypotheses concerning hallucinations

The encounter between psychoanalysis and psychosis occurred very early
on: many analytic intuitions stemmed from the observation of psychotic
states or were used to explain them. For example, the theories of primary
narcissism, autoerotism, and withdrawal of libido from the outside world
owe their existence to the study of psychotic processes. Many characteristics
of the unconscious, such as the primary process, timelessness, and the
absence of contradiction, closely resemble those of psychosis, understood as
an invasion of the ego by the unconscious. The idea of hallucinatory wish-
fulfilment in children is also based on this analogy.
The earliest psychoanalytic theories linked psychological disorders to cor-
responding phases of infant development. According to such theories, men-
tal disease corresponded to primitive modes of psychic functioning and
there was an equivalence between the primitive and the pathological.
Psychosis too was included in this hypothesis: Freuds view was that
psychosis coincided with an autoerotic withdrawal and a regression to
forms of primitive development.
Melanie Klein (1946) also believed that the impulses and anxieties
underlying states of schizophrenic persecution corresponded to primitive
Copyright 2014 Institute of Psychoanalysis Int J Psychoanal (2014)

functioning dominated by sadism and the death drive. In her opinion, the
disposition to psychosis depended on primitive impulses and anxieties which
were normally transformed in the course of infantile development. If this
did not happen, the psychotic nuclei remained unmodified and were
destined to emerge in adulthood.
Bion (1967), on the other hand, presented a model in which psychosis did
not represent a return to primitive stages of development, but was rather
the expression of an altered capacity to think: the disorder concerned the
functions which transformed sensory perceptions into thoughts. For this
reason, the patient was unable to work through the events of his mental life
on the symbolic level.
It is beyond the scope of this paper to consider in psychoanalytic terms
the phenomenological and dynamic complexity of the psychotic state.
Among the many contributions on the subject (Abraham, 1924; Arieti,
1955; Arlow and Brenner, 1969; Aulagnier, 1985; Benedetti, 1980; Bion,
1957, 1958, 1965, 1967; Boyer, 1966; Fairbairn, 1952; Federn, 1952;
Freeman, 2001; Freud, 1894, 1911, 1915, 1923, 1924, 1932; Fromm-Reich-
mann, 1960; De Masi, 2000, 2006; Hartman, 1953; Jackson, 2001; Katan,
1954; Lacan, 195556; Lombardi, 2005; Lucas, 2009; Ogden, 1982, 1989;
Pao, 1979; Racamier, 2000; Resnik, 1972; Rey, 1994; Rosen, 1961; Rosen-
feld D, 1992; Rosenfeld H, 1965, 1969, 1978; Searles, 1965; Segal 1956,
1991; Symington, 2002; Winnicott, 1954, 1971), we choose to discuss only
those that are helpful to the psychoanalytic understanding of the nature of
the hallucinatory state.
Freud addressed the subject of hallucinations from a number of differ-
ent points of view, some of which are difficult to integrate into a
consistent whole. At first (Freud, 1894), he saw hallucination in terms
of the model of repression, regression, and the return of the repressed.
In distancing itself from an incompatible representation, the ego also
detached itself from reality, because pieces of reality were linked to the
incompatible representation. Later, in his account of the case of Schre-
ber (Freud, 1911), he attributed hallucinations to the unconscious con-
flict arising from Schrebers unconscious homosexual impulses. In his
consideration of regression (Freud, 1915), he noted that in normal cir-
cumstances reality testing made it possible to abandon hallucinatory
wish-fulfilment, whereas in the psychoses the older mode was re-
established.
Elsewhere, Freud (1924) puts forward the interesting hypothesis that
psychotic reality stems from the patients own bodily sensations, through
the confusion of proprioceptive with exteroceptive reality. He now postu-
lates that entry into psychosis takes place in two stages. Firstly, the ego
disavows (rejects) reality and detaches itself from it; then it creates a new
reality by means of a delusion or hallucination. The purpose of this new
creation is to compensate the ego for the damage sustained. The anxiety
aroused is due not to the return of the repressed (as in neurosis), but to the
re-emergence of the rejected part of reality.

In the mature period of his production, Freud (1937, p. 267) surprisingly

returns to the subject of hallucination and links it to memory. He writes
that non-psychotic hallucinations contain memories of remote events which
the child heard or saw before the acquisition of the faculty of speech:
Perhaps it may be a general characteristic of hallucinations to which sufficient

attention has not hitherto been paid that in them something that has been experi-
enced in infancy and then forgotten returns something that the child has seen or
heard at a time when he could still hardly speak and that now forces its way into
consciousness [. . .].
However, psychotic hallucinations, included in delusional systems, are

here also attributed to memories of the past that seek to emerge from obliv-
ion, albeit in extremely distorted form.
Federn (1952) distinguishes two boundaries of the ego: the external
boundary, which separates the ego from the external world (this
boundary being clearly understood as a psychological characteristic
and not as a real boundary of the individual), and the internal bound-
ary, which separates conscious from unconscious. In his view, the
boundary of the ego is ultimately a kind of sense organ that automati-
cally distinguishes what is real from what is unreal. If for any reason
the egos external boundary is lost, external objects are perceived as
strange or unreal. According to Federn, psychosis affects the unity and
boundary of the ego, which loses its homogeneity and delimitation in
space. In this case, the patient can no longer maintain the distinction
between conscious and unconscious, and experiences dreams as if they
were delusions or hallucinations.
Unlike Freud, Federn holds that patients do not abandon reality, but
instead develop falsified ideas that alter the perception of personal identity.
Another important difference concerns the conceptualization and meaning
of delusional experience. Whereas Freud sees delusion as an attempt at
reconstruction after the psychotic catastrophe that is, at libidinal recathex-
is of the object by the ego Federn considers it to be a consequence of the
falsification of reality and of the loss of the egos boundaries.
For Bion, hallucination is the result of a mental operation that destroys
alpha-elements (symbols), reducing them to fragments that cannot be
thought but can only be evacuated. This evacuation takes place
through the sense organs, whose direction of operation is reversed, so
that undigested beta-elements are expelled into the outside world
together with traces of the ego and superego, thus giving rise to bizarre
objects (Bion, 1958, 1965). For this author, transformation in halluci-
nosis too is an evacuative phenomenon, but with less disintegration of
the projected material, so that what is expelled are sensory elements
with scraps of meaning still attached to them. Unlike hallucinations,
transformations in hallucinosis thus entail not the perception of objects
that do not exist in external reality, but the perception of non-existent
relations (Meltzer, 1983). Some patients use the omnipotence implicit in

hallucination as a method of gaining independence from any object

through the use of their sense organs for the purposes of evacuation
into a world which they themselves have created.
An original insight into the subject of hallucinations is provided by
Lacan (195556). In his view, the structuring of psychosis is the out-
come of the primal lack of a signifier capable of polarizing signifieds,
given that such a signifier corresponds to a highway in the psyche. It is
the absence of this signifier that causes the subject to lose his way
owing to the loss of stable reference points. As we know, Lacan distin-
guishes three orders of functions the imaginary, the symbolic, and the
real which are linked by the function of language. In the event of
foreclosure, as is typical of psychosis, language can no longer perform
its linking function, so that the real and the symbolic are confused, as
with auditory hallucinations. For Lacan, hallucination is the return of
something that has not been processed at symbolic level, but instead
foreclosed, or dissociated from consciousness. The content dissociated
from the subjects personality will therefore present itself as an experi-
ence stemming from external reality, so that in hallucination the words
spoken by the unconscious appear as pure id (Miller, 1989).
According to Pao (1979), hallucination in schizophrenic psychosis is
always accompanied by delusion. The author maintains that is it not
possible to separate the hallucination from the delusion. Pao distin-
guishes the acute phase from the sub-acute phase of the psychosis. In
the sub-acute or chronic phase the acoustic hallucination protects
against the egos disorganization and can function as a transitional
object. Hallucination in these cases serves both the patient and the
therapist, as it illustrates to the latter the formers conflicts and needs.
In studying the phenomenon of hallucination, subsequent authors sought
to understand it as a primitive form of perception and therefore turned their
attention to the sensory phenomena observed in autistic children:
Meltzer et al. (1975) consider that an autistic patient has a two-
dimensional mind. Perception of the object is bound up with the
sensory qualities of its surface, and the self too is limited to a sensitive
surface. Relating in an autistic child is characterized by an adhesive
type of identification with the object. An autistic child dismantles the
object, reducing it to its individual, single-sense components. This
results in an inability to assign meaning to stimuli from the outside
world, which are experienced as bombarding the senses.
Frances Tustin (1986) describes a sensory phenomenon that she calls
autistic shapes, which she regards as the precursor of (visual, auditory,
and other) hallucinations. In the view of this author, these phenomena
are present in the psychopathology of autistic adults and children alike.
The shapes are very different from objective, geometrical shapes and
are completely personal. Sounds, odours, tastes, and visual images are
felt as shapes to the touch. They are therefore bizarre creations involv-
ing crude autosensuality. Autistic objects are self-induced bodily sensa-
tions and the product of autosensual activities, but are stimulated by

hard bodily substances (cars, toy trains, etc.). In an autistic child, the
shapes have the function of mitigating the sense of non-existence, and
therefore exert a particular, bizarre fascination.
Piera Aulagnier (1985) postulates that fixation on a geographical or
sensory zone of the body prevents representational or fantasy-related
ideation. The psyche therefore hallucinates not the object but a sensory
perception. These mental experiences (pictograms) are sensory halluci-
nations, which are equivalent, in her view, to Tustins autistic shapes
and Meltzers zonal fixations the starting point for directional rever-
sal of the perceptual apparatus in autistic withdrawal.
This brief review of psychoanalytic theories on hallucinations reveals
differing hypotheses as to their genesis. Having initially been conceived as
of conflictual origin, leading to the disavowal of reality by means of massive
projection on to the outside world (Freud), they were subsequently regarded
as due to a destructive attack on the sense organs (Bion). For Lacan, hallu-
cinations result from the dissociation of the various mental functions due to
foreclosure. Tustin and Aulagnier, on the other hand, take a different view.
These two authors hold that hallucinations stem not from defensive and
destructive psychodynamic processes, but instead from a primitive, epider-
mal, and surface-related excitatory type of perception resembling that
observed in autistic disorders. They are sensory shapes that are unconnected
with thought and have the function of distancing the patient from anxiety
of the void and of non-existence.
Neuroscientific findings
Advances in brain visualization techniques (neuroimaging) have permitted
examination of brain structure and function in vivo and opened the way to
important new findings in the study of human psychopathology. The princi-
pal neuroscientific findings on hallucination are set out in a contribution by
Paul Allen et al. (2008) entitled The hallucinating brain: A review of struc-
tural and functional neuroimaging studies of hallucinations, which gathers
together the most significant studies from 1990 to 2008 and forms the basis
of the following consideration.
Hallucinatory phenomena are known to arise in, for example, cases of
brain damage. This is attributed by Braun et al. (2003) to the destruction
of the inhibitor neurons that modulate the activity of certain areas, which
are then activated in an uncontrolled manner and give rise to hallucina-
tions. In the absence of brain damage, particular areas of the brain corre-
sponding to the specific type of hallucinations have been found to be
activated. For instance, in psychotic episodes with auditory hallucinations,
McGuire et al. (1993) observed activation of Brocas area (the seat of lan-
guage), of the anterior cingulate gyrus (responsible for attention processes),
and of the temporal cortex (in charge of auditory perception and mem-
ory). These areas were found to be inactive when the patient was not
hallucinating.
An interesting finding (David et al., 1996) is that the areas of the brain
involved in the hallucinatory phenomenon are occupied and become imper-

meable to the reception of external stimuli. Hence there is competition

between external sensory perception and hallucination. These authors also
demonstrate that hallucination is preceded by intense preparatory activity,
which is stated to betray the completely unconscious involvement of the
individual in his disorder. Indeed, some authors (Hoffman et al., 2008)
observed a modification of brain activity six to nine seconds prior to the
onset of verbal hallucinations in the left inferior frontal cortex, the inferior
cingulate cortex, and the right middle temporal gyrus. This is considered to
show that the cortical regions which mediate the function of internal
language prepare the hallucinations and become active before the regions
that give rise to the hallucinatory perceptions.
The neuroscientists hold that hallucinations are able to alter the sense of
reality by virtue of a complex modification of the balance between top
down and bottomup circuits, given that the neuronal circuits operate by
topdown and bottomup processing.1
The bottomup processes concern sensory information or perceptions
that travel from lower to higher levels of the brain, the latter being charac-
terized by greater complexity. These higher centres hold the previously
acquired expectations and notions that monitor the incoming data in the
topdown mode and interpret and process those data at mental level. Top
down processing is mediated by circuits leading from the neocortex to the
subcortical structures in such a way that the cortex can control the subcorti-
cal functions. Resting-state hyperactivity of the regions involved in the gen-
eration of hallucinations is an indication of what Allen et al. (2008) call
over-perceptualization: an abnormal or increased bottomup modulation
is established from the auditory cortex to the other cortical regions, so that
the subject experiences and perceives his internal auditory activity with
greater intensity.
Hallucinations result from a malfunction of the topdown system that
is, of the structures responsible for the control and monitoring of the sen-
sory zones from above. Bottomup dysfunction takes the form of hyperacti-
vation of the secondary (occasionally primary) sensitive cortices, thus
facilitating the experience of vivid perceptions in the absence of sensory
stimuli and potentially leading, owing to a disturbance of monitoring and
judgement of reality, to the experience of externality. In hallucination, the
cortical and subcortical centres that regulate emotions are also activated,
thus accounting for the intense emotional component accompanying the
hallucinatory phenomenon.
Northoff and Qin (2011) have developed an original hypothesis about the
neuronal mechanisms underlying hallucinations, called the resting state
1
This terminology is used in the neurosciences and psychology. An example is the study of visual atten-
tion: if attention is directed to a flower in a field, this may be due merely to the fact that the flower is
visually more prominent than the rest of the field. The information leading to the observation of the
flower is conveyed by the bottomup modality. Attention in this case has not been determined by knowl-
edge of the flower; the external stimuli were already sufficient in their own right. If, on the other hand,
the subject is searching for a flower, he already has a representation of what he is looking for, and iden-
tifies the object he is seeking when he sees it. This is an example of the topdown mode of information
use. In other words, in a purposive action, topdown processing (guided conceptually) and bottomup
processing (guided by the senses) interact.

hypothesis of auditory verbal hallucinations. This hypothesis suggests that

auditory verbal hallucinations may be traced back to abnormally elevated
resting state activity in the auditory cortex itself, abnormal modulation of
the auditory cortex by anterior cortical midline regions as part of the
default mode network, and neural confusion between auditory cortical rest-
ing state changes and stimulus-induced activity. The authors hypothesize
that the abnormal restrest interaction may be confused (or taken) by the
brain with restexternal stimulus interaction thereby inferring externally
located voices which in turn leads to the auditory verbal hallucinations.
Northoff and Qin assume resting state abnormalities to be necessary though
not sufficient conditions of auditory verbal hallucinations. Only if combined
with social withdrawal and the consecutive absence of external stimuli, rest
rest interaction may yield large enough neural differences to induce mental
states and thus auditory verbal hallucinations. If, in contrast, there is a high
continuous social input and thus external stimuli, restrest interaction, even
if increased, is much more likely to be suppressed by the demands of the
external stimuli and its induction of stimulus-induced activity, e.g. rest
stimulus interaction.
The eyes of the mind

Hallucinations, or rather voices, are present not only in the psychoses and
cases of brain damage. The relevant literature includes reports on many
subjects with hallucinatory (in particular, auditory) phenomenology who
cannot be regarded as delusional or psychotic and who do not exhibit other
manifest psychiatric or neurological disorders.2 These individuals are aware
that the voices are of internal origin and are not afflicted by the same
devastating mental states as psychotic patients. Sacks (2012) underlines that
this kind of phenomenon varies enormously, depending on the sort of hallu-
cinations that occur, how often they occur, and whether they are contextu-
ally appropriate.
Hallucinations in the psychotic process are very different in character
from those appearing in other mental states, and are often structured in a
form closely related to the preceding delusional system. For this reason, hal-
lucinatory phenomena often confirm the reality of the delusion to the
patient.
This was the case in a psychoanalytic patient who felt persecuted by a
group of foreigners who he thought were plotting against him and were out
to kill him. For a long time, his sessions were replete with detailed, anxiety-
laden descriptions of all the diabolical actions undertaken by the criminal
organization. The patient had convinced himself that, to keep him under
surveillance, the enemies had installed microphones and video cameras in
his home. At one point, the analyst suggested that he bring one of these
video cameras along to his session for examination of its nature. The
patient said that this was impossible because the video cameras were so
absolutely tiny as to be virtually invisible. When the analyst asked him how
2
Even Socrates heard voices.

he managed to see them, he replied that he saw them with the eyes of the
mind.
An interesting paper on the subject by Kenneth Hugdall (2009) uses the
evidence of neuroimaging and a battery of tests to demonstrate the differ-
ence between patients who hear inner voices and recognize them as such
and those who, on the other hand, attribute them to the outside world and
are therefore hallucinating. The experimental system was extremely rigorous
and complex, but we shall concentrate on the test results rather than on
their methodology. Whereas psychotic patients with auditory hallucinations
have lost the connection between the temporal hemisphere, in which the
voices are generated, and the prefrontal cortex, the centre of the higher
cognitive functions, subjects who recognize the voices as internal have
retained it. In the latter case, the prefrontal cortex monitors sensory experi-
ence and accurately classifies it as of internal rather than external origin.
According to this research, therefore, in psychotic hallucinations there is a
loss of function of the prefrontal areas which assign meaning to our psychic
experiences and which, in a specific case, help us to distinguish between
what is subjective that is, created by ourselves and what, on the other
hand, appears real but does not correspond to material reality. For the
patient, the voices are real, whereas for an outside observer they are not
authentic.
Limits of comparison
We have so far maintained that the neuroscientific findings on hallucina-
tions are useful because they can be related to the clinically observable
transformations of mental functioning occurring in the course of the
psychotic process. This comparison is still embryonic, partly because neuro-
scientific research is at present only at an early stage. The investigation
concerns a highly complex process. After all, the problem of hallucinations
concerns not only the nature of the perceptual processes or the path
followed by stimuli and the organs which convey them, but, in particular,
the nature of consciousness that is, the capacity to distinguish the percep-
tion of self and of ones environment from a dream or indeed a delusion.
Notwithstanding the many hypotheses (Damasio, 1994, 2010; LeDoux,
2002; Panksepp, 1998; Searle, 1997), the investigation of consciousness is
still highly problematical. For example, some neuroscientists (Damasio,
2010) consider that the brain is characterized by a prodigious ability to
create maps. When the brain creates maps, it also informs itself. The infor-
mation contained in the maps can be used without the involvement of
consciousness, as in the case of motor behaviour. The brain is continuously
informed of our bodily experiences and is always in direct contact with the
body; when it creates maps, it also creates images. At a second stage,
consciousness manipulates these images for specific purposes. The maps are
constructed when the subject interacts with external objects, or when objects
are recalled from the archives of memory.
The creation of maps applies to every sensory mode which the brain is
called upon to construct. It is not easy to determine how mapping takes

place. We only know that it does not involve a mere copy, but that the
overall composition requires the active contribution of the brain. The visual,
auditory, or other images are directly available only to the owner of the
mind in which they are formed. Various research teams have shown that
certain configurations of neural activity in the human sensory cortices cor-
respond to individual classes of objects. Hence perception results from the
brains specific cartographic ability.
However, in the current state of research, no solution has yet been found
to the problem of how the brain can produce sensory maps even in the
absence of external objects or stimuli as in the case of hallucinations. For
this reason, some questions are destined to remain unanswered for the time
being.
If the capacity for imagination that is, the faculty of creating hypothe-
ses in fantasy makes use of maps or images, how does the element that
distinguishes the false from the real come to be lost? In other words, if the
brain is able to construct as-if maps (Damasio, 2010) to predict the effects
of a given action instead of performing it, how does it happen that the sim-
ulation does not remain simulation? Is it possible for extreme emotional
states to construct maps even in the absence of external stimuli? Or can the
brain, in the case of hallucinations, forge a direct relationship with the
body, from which it receives erroneous information, instead of remaining
receptive towards the environment as in the normal situation?
Sensation
Partly owing to the contributions of Infant Research and certain neurosci-
entific findings, sensation has increasingly come to be regarded as an impor-
tant element of psychic development. Edelman and Tononi (2001) point out
that the stimuli to which a child is exposed from birth trigger and reinforce
specific schemata of neuronal activity. It is sensory stimuli that regulate the
anatomical and cellular organization of the developing nervous system
(Shore, 1994). A large number of experimental observations show that,
where a child has received insufficient sensory stimulation or lacked emo-
tional attunement during the critical period for the formation of attachment
bonds, this results in behaviour that will remain abnormal or maladaptive
throughout life.
If bodily sensory needs are appropriately satisfied, sensory gratifications
therefore come to be included in an emotional context. Physical tenderness
or kisses become exchanges with a relational quality. For this reason, sen-
sory experience differs in meaning according to the meeting of emotional
state (topdown) and sensory stimulus (bottomup). If the emotional/affec-
tive state predominates, the sensory stimulus is recorded in a relational con-
text and pleasure assumes the character of an emotional exchange.
But what happens in the case of pathology? In the absence of an
adequate emotional contribution from the caregiver, the child uses his own
body for the purposes of arousal. Sensation is then in the foreground, but
without the relational character that develops only within a situation of
good affective care. To combat a threatening sense of dissolution, a

deprived child clings to a range of bodily sensations and stimulations which

can serve to hold the scattered parts of the personality together.
Sensory children
Trinca (2001) postulates that, in psychotic processes, the patient is unable
to think because his mind is saturated with sensory elements that favour the
development of delusions and hallucinations. These archaic, concrete sen-
sory elements blot out the internal world, pervade and dominate the mental
processes, and block the capacity to dream as if they were impregnating
the mind with sense impressions. For this reason, a psychotic patient is
unable to develop the symbolic functions that is, the functions needed to
understand human relations on the intrapsychic level.
These observations are consistent with those of other authors (Bergman
and Escalona, 1949) who have described small children endowed with an
exceptional degree of sensory development, whether visual, auditory, tactile,
or olfactory. These children may be disturbed by sensations that are toler-
ated perfectly well by others of the same age. In all the five cases described,
the children, observed from the age of a few months up to 7 years, incline
more to sensory enjoyment than to human relations, love muffled noises,
and have a powerful sense of smell with a pronounced preference for certain
odours. One of the little girls described in this contribution hates toys, but
when playing with a piece of velvet can enter into a trance state. Some of
these children have vomiting problems from birth, in some cases so severe
as to result in surgery for presumed pyloric stenosis: these children are remi-
niscent of those suffering from merecysm described by Gaddini and Gaddini
(1959), who closed themselves off in their pleasure while ruminating their
food. Such children avoid eye contact with others and abandon themselves
to seemingly ecstatic stupefaction; they sometimes speak at a particularly
early age and then cease to do so.
Psychic withdrawal and the onset of hallucinations

Many authors (Joseph, 1982; OShaughnessy, 1981; Rosenfeld, 1964; Segal,
1982; Steiner, 1987, 1990) have described in particular a set of defences in
the form of a pathological organization that operates within the personality
and dominates it. This structure assumes stability and rigidity over time and
proves difficult to transform in therapy.
In addition to this kind of pathological organization, other areas of the
personality too have been described. Rosenfeld (1971), Klein (1980),
Mitrani (2001, 2008), and Tustin (1972, 1986, 1991) have identified certain
psychic states that correspond to autistic areas cut out of the personality
(Strauss, 2012).
Steiner (1993) uses the term psychic retreat to denote a specific pathologi-
cal organization into which an individual withdraws in order to avoid relat-
ing to the world and experiencing the associated anxieties. According to
Steiner, a psychic retreat is quite stable in character and may persist
throughout life.

It must, on the other hand, be emphasized that in the case of psychosis,

withdrawal, as we prefer to call it, will not only give rise to a severe regres-
sion of the personality, but also radically transform it, sometimes even gen-
erating thoroughgoing symptoms such as delusions and hallucinations.
A useful model for understanding psychotic functioning draws on the
contrast, highlighted by Bion (1957), between the healthy part and the
psychotic part of the personality. The psychotic part not only dominates
the healthy part but progressively colonizes it and overwhelms it until it gets
rid of it entirely. In this way the psychotic individual performs a radical
overturning of thought and of the rules that foster comprehension of
human relations. This is a long-lasting process; it begins in childhood,
generally remains hidden during adolescence and openly manifests itself
during early adulthood. When the healthy part is completely conquered by
the sick part, the crisis emerges which, at times, requires hospitalization and
psychopharmacological treatment.
While healthy children progressively broaden their horizons and knowl-
edge, their psychotic counterparts-to-be proceed in the opposite direction,
withdrawing mentally into a world of gratifying sensory fantasies that sepa-
rate them from real life. Such children use their minds not so much to
understand themselves and the reality around them as, instead, to produce
stimulation or pleasurable perceptions.
The dissociation from psychic reality that underlies the future psychotic
proliferation occurs in this withdrawal, which begins in infancy. This mental
state is particularly obvious in small children, who readily bring the world
of dissociated fantasy to their sessions.
For infantile withdrawal is the crucible of the psychotic part of the per-
sonality that is destined later to colonize the healthy part and create the
psychotic pathology. In the case of psychosis, the withdrawal or the equi-
librium between the psychotic and healthy part of the personality may
also remain balanced for a prolonged period, but it usually tends to
expand and overcome the rest of the personality. It corresponds to the
psychotic part of the personality, whose aim is to invade and swallow up
the healthy part.
The world of psychic withdrawal is constantly fuelled by sensory fantasy
activity that is never integrated with actual reality, to which the affected
child does, however, retain partial allegiance. It corresponds to the creation
of a dissociated reality that sucks the life-blood out of emotional and
psychic development because it closes off the channels through which
growth-mediating experiences flow (De Masi, 2006).
To describe the isolation of psychotic patients, Freud invoked autoero-
tism; he regarded this pathological process as the repetition of a primitive
level of development in which the newborn lived withdrawn into the body.
Hence the term autoerotism describes both psychotic withdrawal and the
objectless phase of human development that is, the primitive phase in
which a child, concentrating on his own bodily sensations, is seemingly
ignorant of the presence of the world around him. Freuds idea was devel-
oped firstly on a theoretical level by Bion with the model of the psychotic
part of the personality and subsequently by Steiner with the concept of the
psychic retreat. Freuds insight remains useful for understanding certain

aspects of the psychotic state, such as, for example, the detachment from
emotional reality, withdrawal into the subjects body, and the production of
hallucinations. The latter, after all, arise in the body and are stimulated by
bodily sensations.
The term dissociation in this case does not refer to a defensive process in
which a part of experience is detached from psychic reality and erased from
memory in order to preserve at least a precarious balance within the person-
ality, as occurs, for instance, in infantile sexual trauma. In psychic with-
drawal, the sensory world of fantasy constitutes another reality that never
coincides with relational experience. While existing alongside each other, the
two visions those of sensory withdrawal and of psychic reality cannot
be integrated with each other and are unable to give rise to insight. When a
patient resorts to the world of dissociated fantasy, he blocks access to the
perception of psychic reality. The more the process tends towards the preva-
lence of withdrawal, the greater the risk that the patient will be overcome
by psychosis.
This seems to us to be the fundamental transformative process at work in
the patients mind, which, in increasingly detaching it from reality, leads
him into the world of delusions and hallucinations. Dissociation from
psychic reality ultimately gives rise to hallucinations, which are, precisely, a
consequence of the sensory use of the mind. One reason why sensory with-
drawal eventually conquers the rest of the personality is that the patient,
while conscious of having a secret life which he pursues in the withdrawal, is
not aware of the destructive effects on his personality.
Our clinical hypothesis is that hallucinatory phenomena represent the
outcome of a prolonged distortion of the psychotics mind which he himself
undertakes although he is unaware of so doing. The psychotic part uses the
mind not as an instrument for relating to others (as an organ of knowledge),
but to generate a sensory world in order to obtain a special, regressive type
of pleasure. Hence the primitive infantile withdrawal into a world of sen-
sory fantasies. This process cannot of course be deemed the only cause of
the pathology, but seems to us to be one of the principal ways in which it
develops the hallucinatory state. In some cases the hallucinations are at first
pleasurable in nature and satisfy the psychotic patients need to identify
with grandiose, omnipotent objects.
Alvise, the patient we will describe later and who jumped off a flyover
under the power of hallucinations that were accusing him of harbouring a
devilish power, said that, unlike his friends, before his breakdown he had
no need to take drugs. He had discovered an endogenous way of drugging
himself mentally. It was only at a second stage that the process of pleasur-
able alienation had distanced him from contact with reality and the halluci-
natory world had become terrifying. This is because, in the psychotic
process, the newly created sensory reality eventually runs out of control,
dominating and completely invading the healthy part of the personality.
The auditory (or visual) hallucinations become malevolent, and the delu-
sions of grandeur turn into persecutory states.

Psychotic hallucinations
In the psychotic patient fantasy no longer possesses the imaginative quality
of as if and assumes the character of concrete thought. As the above clini-
cal examples show, although the mode of entry into the psychotic world dif-
fers from patient to patient, hallucinations bear witness to the extreme
development of a psychic withdrawal in which a preformed internal reality
is externalized with all the accompanying contents of anxiety or violence.3
Being endowed with a sensory and concrete quality, hallucinations easily
deceive the patient, owing to their resemblance to the perceptions that
describe the world about us in normal circumstances. Visual hallucinations
could be said to arise from seeing with the eyes of thought, and their audi-
tory counterparts from hearing with the ears of thought.
Hallucinations in the psychotic state are congruent with delusion, of
which they seem to represent a development. When they appear, the psychotic
process moves on from the ideational (delusional) level to a more thor-
oughly sensory plane. In these patients, the hallucinatory symptom arises
from sensory perceptions that are so clear and incontrovertible as to
prevent recourse to the normal experiences necessary for reality testing.
They in fact constitute a mental state in which hallucinations are as it were
prepared by the delusional psychotic part that dominates, seduces, and
intimidates the patient.
An author/patient called Perceval (Bateson, 1961), who wrote the history
of his illness after his discharge from hospital, graphically illustrates the
process of progressive emergence from the hallucinatory world. Towards
the end of his confinement in the asylum, when gradually coming out of his
psychosis, Perceval was able to distance himself from the voices that had
tormented and held sway over him for years:
Here it was that I discovered one day, when I thought I was attending to a voice
that was speaking to me, that, my mind being suddenly directed to outward objects,
the sound remained but the voice was gone [. . .]. I found, moreover, if I threw
myself back into the same state of absence of mind, that the voice returned [. . .];
and, prosecuting my examinations still further, I found that the breathing of my
nostrils also, particularly when I was agitated, had been and was clothed with
words and sentences [. . .]; from which I concluded that they were really produced
in the head or brain, though they appeared high in the air, or perhaps in the cor-
nice of the ceiling of the room [. . .]
(Bateson, 1961, p. 294f.)
It is interesting to note Percevals observation that the voice was gone

when his attention was directed to outside objects, whereas it returned in
the state of absence of mind. Hence the hallucinatory reality and that of
attention directed to the outside world are mutually antagonistic. When one
3
In most cases hallucinations in the psychotic process are secondary to delusion and therefore of later
onset, as is borne out by the fact that in drug treatment they disappear first (initially their intensity only
is diminished). The delusional ideation, for its part, is more stubborn and persists for longer (Schneider
et al., 2011).

prevails, the other disappears. For the creation of the hallucinatory state, a
mental condition of passive acquiescence appears to be necessary. While
recovering from his illness, Perceval is seemingly doing his best to recognize
the existing of the outside world and thereby to escape from the power of
the delusional fantasy that has kept him prisoner and rendered him passive.
The patients we discuss below are all characterized by having a psychotic
part prevailing over the rest of a healthy personality. This is the situation in
which delusions and hallucinations clinically develop. The following cases
are merely psychopathological examples of various forms of hallucinatory
activity: we are not aiming to illustrate the clinical work undertaken in each
individual case, with the analysis of any eventual transference or counter-
transference development.
Berta
Berta is 7 years old when she first comes for a consultation.4 The parents
are worried because she is often agitated, irritable, and subject to fits of cry-
ing and rage. She puts objects into her mouth, constantly repeats the same
sentences, and has difficulty in socializing with her schoolmates of the same
age.
In the first consultation, the therapist is surprised by how easily Berta
separates from the mother figure. What worries him is the lack of eye con-
tact, as if she were somewhere else. On entering the room, the little girl
places some dolls on the desk, heads for the soft play area in the corner
(which takes the form of a mattress), and begins to show how elastic she
is. She explains that she was very frightened about coming along to the ana-
lyst: I thought it would be like coming to Dr . . ., who operated on my
throat.5
Berta has a rich fantasy life, is highly imaginative, and has a very
advanced vocabulary for her age. She is later to talk for a long time about
secrets that cannot be divulged. Sessions will begin as follows: I have a
secret, but I cant tell it to you. As she subsequently explains, the secrets
also concern the wish to sample her bodily products. She plays a lot with
her saliva and with plasticine, which she often even eats. In one game, she
hides a tiny little goat in the plasticine, and then laboriously causes it to
re-emerge.
Eventually the game with the little goat encased in plasticine proves no
longer capable of protecting her from the worlds ferocity, as the animal is
impaled on the horn of a rhinoceros. Berta sometimes uses a doll represent-
ing a male figure as if it were a ball: she shapes it, throws it, and deliber-
ately avoids catching it in flight. Ive killed it . . . hundreds of times . . .,
she pronounces in one session; and, in another: I am a serial killer. She
now seems to be identified with a terrifying character, which apparently
confirms her perception of being very bad and therefore a possible victim of
4
This patients material was supplied by Dr Agostino Napoletano, who has kindly allowed us to use it.
Berta was treated with a two-sessions-a-week child psychotherapy.
5
The girl has a prominent scar on her neck from surgery on the hyoid when she was very small. Such sit-
uations tend to return in the hallucinations of disfigured little girls.

sadism. The psychotic transformation is depicted in a dream: I dreamt that

my toy turned into a vampire.
During the first few months of her therapy, the patient already says every
so often that she can see the devil; indeed, on one occasion she claims to
see him during the course of the session itself. She is utterly convinced:
There he is behind you, watch out . . . help, help, the doors locked . . . the
fiend has locked it . . . What an absolutely ugly face . . . his eyes are red
. . . its dark . . . you cant see his nose, or his mouth either.
At home she is terrified by her dolls, stretched out on a shelf: They talk
. . . I can hear them; they want to go into the kitchen for some knives . . .
perhaps they want to kill me, the fiends. Berta says she has never liked her
new house because it is infested with dead little girls, whom she sees wan-
dering up and down the stairs: They are two little girls dressed in white
who make absolutely sure you cant see their faces perhaps because
theyre disfigured.
Rino
6
Rino is 20 years of age and comes for a consultation in November after
spending four months in hospital on account of a psychotic breakdown:
during July he succumbed to persecutory delusions, visual and auditory hal-
lucinations (of a persecutory and imperative nature), severe behavioural dis-
turbances, and fits of destruction. The delusions at first involved mainly
persecution by members of a gang of young drug addicts (of which Rino
had been a member for some years), who subjected him to terrible threats
and physical violence; the delusions then became more complex, with the
entry on the scene of Mafia gangs and Islamic terrorists (eventually he came
into the sights of Osama bin Laden). The patient attributed the actual onset
of the delusion to a specific episode: a challenge by one of the boys in the
gang who came to his house with a girl (whom Rino also fancied) and
provoked him with his stare. Eventually Rino had given him one of his
fluid-laden looks that was so powerful that the other had been utterly
floored and forced to flee. The persecution had begun shortly afterwards
and Rino had tried to escape to Rome, where he had an uncle and aunt;
they then managed to bring him back to Milan and have him admitted to
hospital. The auditory hallucinations had at first been characterized by
good and protective voices (priests from his infant school, or teachers), but
the voices then became bad and satanic (the gang, Mafia people, and crimi-
nals). The voices had then become particularly threatening, with the inter-
vention of Islamic terrorism, and had almost persuaded him to commit
suicide by jumping from a balcony: If you jump, you will at least not be
recruited by the terrorists as a suicide bomber. In the first few days of his
confinement in hospital, the patient had also suffered from tactile hallucina-
tions, which the patient experienced as terrible violence inflicted on his body
by the persecutors. The gang that was persecuting him began to torture him
physically, driving nails into his skin and striking him with hammer blows.
6
Rino was treated with a two-sessions-a-week psychotherapy, in vis-
a-vis setting.

These hallucinations reinforced the delusion, of which they were a corollary.

The patient comments: When I was in hospital, my enemies the members
of the gang filled me with nails, drove them into my skin, and struck me
with hammers. The pain was terrible. The worst thing about the skin hallu-
cinations was that I felt the pain, as if it was real. Have you any idea what
that means?
When Rino was discharged and back home, the outside world came to be
experienced as extremely dangerous. In one session, he describes a halluci-
nation he had on waking from a particularly anxiety-laden, persecutory
dream. A severed wolfs head had appeared before his terrified eyes. During
the session the patient explains how he sees the world as a dangerous gang
war, saying: Outside, Doctor, the situation is homo homini lupus! This
comment links up with the terrifying visual hallucination of the severed
wolfs head.
More recently, Rino comes along to his session and tells me that he has
been dropped by Tania, his first girlfriend. She hates me, he says, she
comes right up to my ear, I see her and hear the bad words she pronounces.
Its a hallucination. Ive learnt to keep her at bay; I know what it is, but,
you see, when you have a hallucination you are ill your head is all upside
down.
The patient says that, at this point in his therapy, he is aware that it is a
hallucination, even if he cannot control it.
Alvise
7
Alvise suffered a serious psychotic episode at the age of 25, when he was
admitted to hospital for two months and underwent drug treatment. The
breakdown had culminated in a suicide attempt: while on holiday, he had
jumped off a flyover while under the delusion of harbouring a devilish
power within that made him totally destructive. Alvise had felt that he
could enter telepathically into other peoples minds, and this had triggered
his attempt on his own life.
In the first two years of his analysis, Alvise often felt hated and despised
by people so that he avoided contact with neighbours, strangers, and later
also friends. In a second phase, these perceptions became organized as audi-
tory hallucinations. Alvise had become a negative entity that lived in the
minds of others and was universally despised. The hallucinations would arise
without warning, attacking him with disparaging accusations and plunging
him into a state of terror. It was impossible to suggest to the patient that the
hallucinations stemmed from his own mind; he really could see and hear
people speaking ill of him, and hear the neighbours commenting on or allud-
ing to his insanity. On one occasion he described a hallucinatory attack
(involving the usual comment Hes mad, mad as a hatter) after a row with
his mother, who had seemed to him overbearing and intrusive. Alvise said
that if he rebelled against the voices, he would be persecuted even more;
he felt that an aggressive counter-attack on the persecutors would have
7
Alvise was followed with a classical psychoanalytic setting (four sessions a week on the couch).

brought back the confusion and the catastrophic sense of guilt. So he could
only submit with resignation to the aggression of the voices.
Alvise seemed to have introjected an annihilating object that had become a
part of himself. Working with the patient, especially in the intervals between
hallucinatory episodes, I was later able to identify a specific time, tantamount
to a period of incubation, when the destructive, guilt-inspiring voices came
into being. Whenever, outside the sessions, he happened to feel sad and
isolated from everyone, this caused hatred and violence towards the rest of
the world to grow within him. The culmination of the paroxysmic hate
coincided with the collapse of the psychic boundary (the loss of his psychic
cranium and shield), resulting in perceptual holes that were the source of
the peoples aggressive thoughts which ran him through and terrified him.
We gradually came to understand that the mental state into which he
withdrew, in which the sadomasochistic isolation of a victim was mixed
with hate, was the fertile soil for the production of the hallucinations. The
hallucinatory experience was preceded by loss of the perception of psychic
reality and of the separation between himself and others (he was acquainted
with other peoples thoughts, which subsequently became hallucinatory
attacks).
The mindbody relationship

While psychosis represent a progressive, dissociated withdrawal from the
world, neuroscientific research can document the neurobiological foundations
of this process, which is found to be accompanied by a modification of the
relations between the brains thought and perception centres. During the
course of the hallucinatory process, the perceptual sensory areas become
hyperactive, whereas the higher functions that ought to monitor the judge-
ment of reality operate at a reduced level. To give rise to hallucinations and
gain dominion over the rest of the personality, the psychotic process must
therefore inhibit the higher functions while at the same time activating the
perceptual sensory zones.
In other words, there is a loss of the connection between the higher corti-
cal functions, responsible for assigning meaning to an individuals experi-
ence, and the purely sensory functions monitored by the former and
involved in the correct attribution of reality.8 When the connection between
the higher, conceptual faculties and the sensory functions has been severed,
self-creative perceptions are perceived as real; conversely, if the connection
between the higher and lower areas is preserved, the voices are experienced
as an internal dialogue and not as hallucinations.
Furthermore, the sensory zones that give rise to hallucinations become
active only when the adjacent language-related areas are activated. What
8
This may be one reason why dreams too appear to the dreamer as real events, but are perceived as
having been dreamt when the dreamer regains consciousness on waking. In the hallucinatory process,
on the other hand, the perception lacks anything to compare it with and remains stable, concrete, and
real. The father hallucination in the dream of Blechners (2005) patient is highly instructive in this
connection.

the patient expresses in sensory terms when hallucinating is thus prepared

for in words (Hoffman et al., 2008).
This had already been demonstrated decades earlier by chance clinical
observations, but was confirmed more recently by the statistical evidence of
neurophysiological studies (Stephane et al., 2001), which confirmed the
simultaneous activation of Wernickes area and Brocas area in auditory
hallucinations. Whereas the former area generates hallucinations, the latter
activates the vocal musculature, the activation being detectable by electro-
myography and resulting in weak phonation that can be picked up with
high-sensitivity microphones close to the larynx. The vocal cords and the
pharyngeal muscles are activated simultaneously with perception of the
auditory hallucination.
Psychosis develops by a gradual process of regression in which the indi-
vidual decathects psychic (relational) reality and withdraws into a personal,
bodily, and sensory space of his own (Perceval). The opposing realities are
not external and internal, but psychic and sensory. In psychosis, the latter
develops at the expense of the former. This suggests that, for the generation
of the psychotic process, mental functioning must restrict itself, cutting out
the more mature functions, which can thus no longer assign real meaning to
the world around the subject and to his psychic experience.
To this end, the patient must sever the connection with the cognitive
brain functions that keep him in touch with psychic reality in particular,
the function that distinguishes between what is produced internally and by
the senses, on the one hand, and what exists outside him, on the other. This
process might, to a much more limited extent, underlie states of autosugges-
tion, from the most insignificant to those bordering on hallucination.
During a psychotic episode, the patient lives his life enclosed in his bodily
monad, in a hostile dimension that separates him from the rest of the
world. He feels thoughts, but cannot think them. When the higher func-
tions (for which the prefrontal lobes are responsible) are inhibited, the
patients attention to the external, relational world is reduced and his men-
tal space is restricted. An important phenomenon in hallucination is that
the sensory areas on which the hallucinatory process is centred remain occu-
pied, and are therefore unable to receive perceptual communications from
the outside world.
Some considerations
As we have seen, neuroscientists use the technique of neuroimaging to dem-
onstrate what happens on the neurophysiological level (that of the brain) as
the psychotic process progresses in the psyche (the mind). The psychosis over-
comes the mind because it deactivates and paralyses the faculties of discrimi-
nation and thought that are located predominantly in the prefrontal regions.
In practice, the creation of the psychotic sensory retreat contributes to the
permanent enfeeblement of the capacity for discrimination and self-criticism.
This is because the patient can succeed in remaining in the self-excitatory sen-
sory retreat only by inhibiting the operation of the brain centres essential to
emotional reception of the environment and to the judgement of reality.

Univocal, concrete sensory perception therefore replaces the faculty of

thought. In this way, the world perceived by the patient remains within the
sensory channels, which expand as if they were the whole world hence the
loss of separateness and of the distinction between outside and inside.
The perception created in fantasy remains sensation. So it is not only real,
it is also true, in other words incontrovertible. It structures itself as a reality
of the senses that cannot be brought into question. It is pure sensoriality
that has no access to representation or symbolization (Segal, 1957). Arlow
and Brenner (1969. p.10) wrote:
Instead of being experienced as a daydream, it [the fantasy] is experienced as a delu-

sion or hallucination. What determines whether it is one or the other is the presence
or absence of sensory elements in the fantasy. If there are such elements, the result
is a hallucination. If there are none, it is a delusion.
The hallucination avails itself of the capacity of the psychotic part of the
personality to sensorially transcribe an imaginative thought. During the hallu-
cinatory experience, the patient does not think, he sees or feels.
From the neuroscientific point of view, sensory stimuli do not reach the
centres responsible for the cognitive functions, where they could be analysed
and distinguished, but are detained on the level of the sensory areas, where
they are used autistically. As Hugdall et al. (2009) have shown, when the
connection to the prefrontal regions remains intact, the voices retain their
connotation of reality; they are not projected to the outside world and are
perceived as inner voices.
The psychotic solution appears to be an attempt to transform the mental
apparatus by way of the acquired capacity to alter the organs of perception,
thus compromising the sense of reality and transforming the personal iden-
tity. In this way, the psychotic part of the personality tries to annihilate
human relations and blots out the sense of awareness of self, the body, and
the mind. Once under way, this transformation of the mind is difficult to
stop, precisely because it confuses the patient as to the pathological nature
of the process, which is mistaken for the opening up of a stimulating new
perspective of perception and awareness.
The alteration of the relations between interdependent areas of the brain
raises the problem of whether these modifications can be reversed. In one
sense, the reversibility of the psychotic transformations and the disappear-
ance of the associated symptoms are not easy to bring about without the
assistance of psychopharmaceutical drugs, which can attenuate or remove
the hallucinatory symptoms, albeit without acting on their underlying emo-
tional or psychological causes. Hallucinations or delusions also represent
inappropriate responses constructed by the patient to insoluble problems
and always leave traces that facilitate their repetition.
Conclusions
The hypothesis put forward in this contribution takes account of the possi-
ble biological foundation of psychosis and of the complex relationship

between mind and brain. In particular, on the basis of important neurosci-

entific findings, we have seen that the mental transformations occurring
during the course of the psychotic process have correlates in corresponding
changes in the bioneurological substrate of the brain. This is an area in
which psyche and soma meet and confront each other at close quarters, to
the extent of forming a single, reciprocal interface.
From this point of view, the findings of the neurosciences concerning the
modifications of sensory brain structures and their arousal and occupation
in hallucinatory phenomena are important evidence in favour of a connec-
tion between clinical symptoms, subjective experience, and the neurobiologi-
cal substrate.
Such an alteration in the functional relations between areas of the brain
might also explain what happens in subjects who experience hallucinations
without succumbing to actual pathology. Psychotic hallucinations, on the
other hand, are the outcome of a transformative process accompanying the
loss of perception of reality, which therefore involves the entire personality
and is not readily reversible.
In this connection, Bion (1967, p. 39, our emphasis) writes:
The patient feels imprisoned in the state of mind he has achieved and unable to
escape from it because he lacks the apparatus of awareness of reality which is both
the key to escape and the freedom itself to which he would escape.
In other words, when a psychotic patient becomes the prisoner of false

hallucinatory identities, he is no longer in possession of the apparatus of
consciousness of reality, the only possible path to reconstruction of his real
identity. For this reason, emergence from psychotic withdrawal to confront
psychic reality becomes an experience of catastrophic depersonalization.
Translation of summary
Halluzinationen im psychotischen Zustand. Psychoanalyse und Neurowissenschaften im Vergl-
eich. In diesem Beitrag untersucht der Autor unter Ber ucksichtigung wichtiger Erkenntnisse der Neuro-
wissenschaften wie auch der psychoanalytischen Forschung die Bedeutung der tiefreichenden
Verzerrungen, die das mit halluzinatorischen Phanomenen einhergehende psychische Funktionieren
begleiten. Neurowissenschaftliche Studien belegen, dass Halluzinationen den Realitatssinn infolge kom-
plexer Veranderungen des Verhaltnisses zwischen Top-down- und Bottom-up-Schaltkreisen des Gehirns
verzerren. Die Autoren des Beitrags postulieren halluzinatorische Phanomene als Ergebnis der langerfris-
tigen, verzerrten Anwendung seines psychischen Apparats durch den Psychotiker. Im halluzinatorischen
Zustand benutzt der psychotische Teil der Pers onlichkeit den psychischen Apparat, um autoinduzierte
Sensationen hervorzubringen und eine spezifische Art regressiver Lust zu erzeugen. Die Psyche wird
daher in diesen Fallen nicht als Organ der Erkenntnis oder als Instrument zur Vertiefung
zwischenmenschlicher Beziehungen benutzt. Der halluzinierende Psychotiker zieht die Besetzung der psy-
chischen (relationalen) Realitat zur
uck und isoliert sich in seinem pers
onlichen, k
orperlichen und senso-
rischen Raum. Die polaren Realitaten betreffen nicht allein Auen und Innen, sondern auch Psychisches
und Sensorisches. Dementsprechend k onnte man sagen, dass visuelle Halluzinationen das Ergebnis eines
Sehens mit den Augen der Psyche seien und dass akustische Halluzinationen durch das H oren mit den
Ohren der Psyche generiert werden. Das mentale Funktionieren ist bei diesen St orungen bar samtlicher
reiferer Funktionen; das bedeutet, dass der Umwelt und dem psychischen Erleben des Individuums keine
genuine Bedeutung mehr zugeschrieben werden kann. Neurowissenschaftliche Ergebnisse erleichtern es
zu verstehen, wie der psychische Apparat im psychotischen halluzinatorischen Prozess die Arbeitsweise
eines Korperorgans, in diesem Fall des Gehirns, verandern kann.

Las Alucinaciones en el Estado Psico tico. Contribuciones al Psicoana lisis de las Neurocien-
cias. En esta contribuci on, que toma en cuenta algunos hallazgos importantes en las investigaciones
neurocientficas y tambien psicoanalticas, los autores exploran el significado de las distorsiones profun-
das del funcionamiento psquico que ocurren en los fen omenos alucinatorios. Los estudios neurocientfi-
cos han establecido que las alucinaciones distorsionan el sentido de la realidad debido a una alteraci on
compleja del equilibrio entre los circuitos cerebrales arribaabajo y abajoarriba. Los autores postulan
aqu que los fen omenos alucinatorios representan el resultado del uso distorsionado de la mente que
hace el psic otico, durante un perodo prolongado de tiempo. En el estado alucinatorio, la parte psic otica
de la personalidad utiliza la mente para generar sensaciones auto-inducidas y para lograr una clase par-
ticular de placer regresivo. En estos casos, por lo tanto, la mente no se utiliza como o rgano de conocimi-
ento ni como un instrumento para fomentar las relaciones con los demas. El psic otico que esta
alucinando decatectiza la realidad psquica (relacional) y se retira a un espacio propio, tanto personal
como corporal y sensorial. Las realidades que se oponen no son s olo externa versus interna, sino tam-
bien psquica versus sensorial. Por lo tanto, se podra decir que las alucinaciones visuales se originan a
partir de ver con los ojos de la mente, y las alucinaciones auditivas a partir de or con los odos de la
mente. En estas condiciones, se restringe el funcionamiento mental, anulando las funciones mas madu-
ras, que ya no pueden asignar un significado real al mundo circundante ni a la experiencia psquica del
sujeto. Los hallazgos de las neurociencias facilitan la comprensi on de c omo, en el proceso alucinatorio
psc
otico, la mente puede modificar el trabajo de un o rgano somatico, en este caso, el cerebro.
Hallucinations et e tat psychotique. La comparaison entre la psychanalyse et les neurosciences.

Dans cet article qui rend compte des decouvertes importantes de la recherche dans le champ des neuro-
sciences et celui de la psychanalyse, les auteurs explorent la signification des distorsions profondes du
fonctionnement psychique quon observe dans les phenomenes hallucinatoires. Les etudes neuroscientifi-
ques ont montre que les hallucinations deformaient le sens de la realite en raison dune alteration compl-
exe de lequilibre entre les circuits cerebraux topdown et bottomup. Les auteurs de cet article
postulent que les phenomenes hallucinatoires resultent chez les psychotiques dune utilisation deformee
du psychisme sur une longue periode de temps. Dans les etats hallucinatoires, la partie psychotique de la
personnalite utilise le psychisme pour generer des sensations auto-provoquees et pour atteindre un type
particulier de plaisir regressif. Dans ce cas, le psychisme nest pas utilise en tant quorgane de connais-
sance, ni comme un instrument permettant dentrer en relation avec les autres. Le psychotique halluci-
nant desinvestit la realite psychique (relationnelle) et se retire dans un espace personnel, corporel et
sensoriel qui lui est propre. Les realites qui sopposent ne sont pas seulement externes et internes, mais
egalement psychiques et sensorielles. Les hallucinations visuelles peuvent donc ^etre considerees comme
tirant leur origine des yeux de lesprit et les hallucinations auditives comme etant issues des oreil-
les de lesprit. Dans ces circonstances, le fonctionnement mental est restreint, ce qui porte atteinte aux
fonctions plus elaborees et les rend inaptes a attribuer un veritable sens au monde environnant comme a
lexperience psychique du sujet. Les decouvertes des neurosciences facilitent la comprehension de la facon
dont, dans le processus hallucinatoire psychotique, lesprit parvient a modifier le fonctionnement dun
organe somatique comme le cerveau.
Allucinazioni nello stato psicotico. Psicoanalisi e neuroscienze comparate. In questo contributo,

che mette a confronto i dati psicoanalitici con le ricerche neuroscientifiche, gli autori esaminano il signi-
ficato delle profonde distorsioni del funzionamento psichico che si verificano nei fenomeni allucinatori.
Studi neuroscientifici hanno dimostrato che la distorsione del senso di realta delle allucinazioni e dovuto
a complesse alterazioni dellequilibrio dei circuiti cerebrali dallalto verso il basso e dal basso verso lalto.
Gli autori ipotizzano che i fenomeni allucinatori rappresentino lesito di un uso distorto, prolungato nel
tempo, che lo psicotico fa della propria mente. Nello stato allucinatorio la parte psicotica della persona-
lit
a non usa le mente come organo di conoscenza o strumento per relazionarsi con gli altri ma per pro-
durre sensazioni autocreate e per ottenere un tipo di piacere speciale e regressivo. Lo psicotico che
allucina, disinveste la realta psichica (relazionale) e si ritira in un suo personale spazio corporeo e senso-
riale. Il contrasto non e tra realta esterna e realta interna, come e stato spesso sostenuto, bens tra realta
psichica e realta sensoriale. Si potrebbe affermare che le allucinazioni visive si originano dal vedere con
gli occhi della mente, e le allucinazioni uditive dal sentire con le orecchie della mente. In queste con-
dizioni, il funzionamento mentale e limitato, in quanto elimina le funzioni pi u evolute che, perci o, non
sono pi u in grado di attribuire un significato reale al mondo circostante e allesperienza psichica del
soggetto. Le scoperte delle neuroscienze aiutano a comprendere come, nel processo allucinatorio psicoti-
co, la mente arrivi a modificare il funzionamento di un organo somatico come il cervello.

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Int J Psychoanal (2014) doi: 10.1111/1745-8315.

Hallucinations in the psychotic state: Psychoanalysis

Franco De Masi*, Cesare Davalli, Gabriella Giustino and Andrea

(Accepted for publication 1 May 2014)

In this contribution, which takes account of important findings in neuroscien-

Keywords: hallucination, psychosis, psychic withdrawal, judgement of reality,

The present contribution attempts to establish a parallel between the data

Copyright 2014 Institute of Psychoanalysis

Int J Psychoanal (2014) Copyright 2014 Institute of Psychoanalysis

Some psychoanalytic hypotheses concerning hallucinations

Copyright 2014 Institute of Psychoanalysis Int J Psychoanal (2014)

Int J Psychoanal (2014) Copyright 2014 Institute of Psychoanalysis

In the mature period of his production, Freud (1937, p. 267) surprisingly

Perhaps it may be a general characteristic of hallucinations to which sufficient

However, psychotic hallucinations, included in delusional systems, are

Copyright 2014 Institute of Psychoanalysis Int J Psychoanal (2014)

hallucination as a method of gaining independence from any object

Int J Psychoanal (2014) Copyright 2014 Institute of Psychoanalysis

Copyright 2014 Institute of Psychoanalysis Int J Psychoanal (2014)

meable to the reception of external stimuli. Hence there is competition

Int J Psychoanal (2014) Copyright 2014 Institute of Psychoanalysis

hypothesis of auditory verbal hallucinations. This hypothesis suggests that

The eyes of the mind

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Int J Psychoanal (2014) Copyright 2014 Institute of Psychoanalysis

Copyright 2014 Institute of Psychoanalysis Int J Psychoanal (2014)

deprived child clings to a range of bodily sensations and stimulations which

Psychic withdrawal and the onset of hallucinations

Int J Psychoanal (2014) Copyright 2014 Institute of Psychoanalysis

It must, on the other hand, be emphasized that in the case of psychosis,

psychic retreat. Freuds insight remains useful for understanding certain

Int J Psychoanal (2014) Copyright 2014 Institute of Psychoanalysis

It is interesting to note Percevals observation that the voice was gone

Copyright 2014 Institute of Psychoanalysis Int J Psychoanal (2014)

Int J Psychoanal (2014) Copyright 2014 Institute of Psychoanalysis

sadism. The psychotic transformation is depicted in a dream: I dreamt that

Copyright 2014 Institute of Psychoanalysis Int J Psychoanal (2014)

These hallucinations reinforced the delusion, of which they were a corollary.

Int J Psychoanal (2014) Copyright 2014 Institute of Psychoanalysis

The mindbody relationship

Copyright 2014 Institute of Psychoanalysis Int J Psychoanal (2014)

the patient expresses in sensory terms when hallucinating is thus prepared

Int J Psychoanal (2014) Copyright 2014 Institute of Psychoanalysis

Univocal, concrete sensory perception therefore replaces the faculty of

Instead of being experienced as a daydream, it [the fantasy] is experienced as a delu-

Copyright 2014 Institute of Psychoanalysis Int J Psychoanal (2014)

between mind and brain. In particular, on the basis of important neurosci-

In other words, when a psychotic patient becomes the prisoner of false

Int J Psychoanal (2014) Copyright 2014 Institute of Psychoanalysis

Hallucinations et e tat psychotique. La comparaison entre la psychanalyse et les neurosciences.

Allucinazioni nello stato psicotico. Psicoanalisi e neuroscienze comparate. In questo contributo,

Copyright 2014 Institute of Psychoanalysis Int J Psychoanal (2014)

Int J Psychoanal (2014) Copyright 2014 Institute of Psychoanalysis

Copyright 2014 Institute of Psychoanalysis Int J Psychoanal (2014)

Int J Psychoanal (2014) Copyright 2014 Institute of Psychoanalysis

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