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A contribution similar to the one presented in this chapter is uncommon in psychoanalytic literature, given that the analyst is unlikely to find himself treating a hallucinating patient, something that is more likely to be observed by psychiatrists who regularly have patients with psychosis or anatomical brain lesions in their care. Although hallucinations may involve any of the senses (sight, hearing, touch, smell and taste), the most studied and commonly occurring are auditory. Of the patients who suffer from hallucinations (for example, epileptic, traumatised and Alzheimer’s patients), I shall confine my discussion to psychotic patients whose hallucinations tend to be an expression of a delusional system.

Important in the study of hallucinations is the judgement of reality: How does the patient assign reality to stimuli that, beyond all reasonable doubt, originate in his mind?

Some points that help us understand this complex subject are provided by Mark Blechner (2005), who has asked himself how we know that something is real or imagined or dreamt. Blechner makes a reference to Kosslyn’s (1994) work on the functioning of a subsystem that, in the awake state, polarises attention on the stimulus to be perceived and renders it as real. It is unclear whether this subsystem assigns this same quality to the dream and the imagination: it has been suggested that in dreams, since the dreamer knows that it is a dream, at least two subsystems that can set one against the other are needed.

Blechner reports the rare case of a patient undergoing psychoanalytic treatment who dreamt of his father, who had been dead for some time. The patient dreamt that his father was alive and continued to think of him as so even after he woke up. On previous occasions, he had imagined that his father was alive but knew that this was just a figment of his imagination. When he awoke from this dream, however, his conviction that his father was still alive remained. This might suggest that the patient had a hallucination in the dream that persisted even after he woke up.

Blechner sustains that intense emotions, mourning in particular, can bring about alterations to the attribution of reality as sometimes occurs to widows who hallucinate their dead partner. This would demonstrate that reality assignment is based not only on our perception of the external world, but also on the brain ascribing to it a particular emotional experience.

Aii interesting neuroscientific experiment has demonstrated that the judgement of reality is deceiving, and its alteration depends on brain structures that can influence the mind (Schacter et al. 1996). An interviewer read aloud a list of words that corresponded to objects. After hearing the words, the subjects read another list in which some of the words in the previous list were included (and had therefore been previously heard), and others were the same as the objects in the previous list but named using a different word (for example, ‘pudding’ instead of ‘cake’). The subjects were then asked whether a certain word was part of the first list or not. Sometimes the participants mixed up the names in the second list with those in the first, whereas at other times they remembered the names in the first list correctly.

Using neuroimaging techniques, the researchers observed that the hippocampus activated when the subject remembered correctly and incorrectly. The difference was that when recall was accurate, the auditory cortex, the seat of auditory memory, activated too (the first list was heard, the second seen); when instead recall was inaccurate, regardless of the participant’s belief, the hippocampus activated but not the auditory cortex.

The researchers concluded that the activation of the hippocampus provides memory with the impression of reality, regardless of whether the event really happened. This explains why, in cases of false memories of abuse, the person can be convinced that the fact really happened, even though it never actually did (Pally 1997).

The psychoanalytic viewpoint

Freud examined the subject of hallucinations from many perspectives that, at times, were difficult to integrate. Initially (1894), he explained hallucinations through repression, regression and the return of the repressed: given that pieces of reality are connected to the incompatible representation, in order to distance itself, the Ego detaches itself from reality, similarly to throwing the baby out with the bathwater. When Freud (1910) described the case of President Schreber, he asserted that his hallucinations were the product of his unconscious conflict connected to repressed homosexual impulses. On the subject of regression. Freud (1915c) wrote that under normal circumstances, reality testing leads to forgoing hallucinatory wish fulfilment, whereas in psychosis, the older hallucinatory mode is reactivated.

Later Freud (1924b) formulated the interesting hypothesis that psychotic reality derives from feelings in one’s own body: that is, the patient comes to consider proprioceptive perception as external. Entering psychosis occurs in two steps: first the Ego rejects reality, then it creates a new one via a delusion and hallucinations; this new creation is the Ego’s compensation for the damage inflicted upon it, and anxiety is due not to the return of the repressed, as in neurosis, but to the re-emergence of the part of reality that was rejected.

Quite surprisingly, in his mature theorizing, Freud (1938a) returned to the subject of hallucinations, linking them to memory and asserting that non-psychotic

Hallucinations 83 hallucinations contain memories of remote events, something that the child heard or saw before he was able to speak:

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 experienced 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.

(p. 550)

And psychotic hallucinations, placed within the delusion systems, likewise cany meaning of past memories that strive to emerge from nowhere, albeit in a deformed fashion.

I had always considered this statement by Freud as a purely theoretical hypothesis until I found Audrey’s account in the book Living with Voices (2009), which I shall briefly summarise.

Audrey’s illness began with hallucinations of crows inside her room, and then one day, they also appeared in the kitchen where she worked as a chef; she started throwing knives at them and needless to say got the sack. Her auditory hallucinations were heard as inner voices; some would criticise her thoughts while others would be supportive. Many years later, when she was in partial remission, Audrey managed to remember that the vision of crows was connected to sexual abuse she had suffered when she was very young under a tree full of crows. Clearly, this was a dissociated traumatic memory that reappeared initially as a hallucinatory perception.

The psychoanalytic contribution

According to Bion, hallucination is the result of a mental operation that destroys alpha elements (symbols), reducing them to fragments that can only be evacuated but not thought. This evacuation occurs through sense organs whose functioning is reversed so that undigested beta elements are expelled into the external world together with traces of the Ego and Super-ego, thus giving rise to bizarre objects (1958, 1965). Transformation in hallucinosis is, for Bion, an evacuative phenomenon too, but it involves less disintegration of the projected material, and consequently, what is expelled are sensory elements with shreds of meaning attached. Unlike hallucinations, transformations in hallucinosis do not involve the perception of non-existent objects in external reality but the perception of non-existent relations (Meltzer 1982a, 1982b). From this we may infer that for Bion some patients use omnipotence implicit in the hallucination as a way to gain independence from any object through the use of their own sense organs as evacuation tools in a world they themselves have created.

An original understanding of hallucinations comes from Lacan (1981), who stated that the structuring of psychosis is the outcome of an original lack of a sig-nifier capable of polarising signifieds; the absence of this signifier is what causesthe individual's bewilderment, depriving him of stable reference points. As we know, Lacan distinguished between three orders: the imaginary, the symbolic, and the real, which he saw as linked by the function of language. When foreclosure occurs, as in psychosis, language can no longer fulfil its linking function; confusion ensues between the real and the symbolic, which is clearly visible in hallucinations. For Lacan, the hallucination is the return of what was not processed at a symbolic level but foreclosed; that is, a real fragment is dissociated from consciousness. The content dissociated from the individual’s personality thrusts its way in as if it were an experience coming from external reality, the unconscious word in the hallucination therefore appearing as pure Id (Miller 2000).

The authors mentioned next have studied the phenomenon of hallucination as a primitive form of perception: hence, their interest in sensory phenomena observed in autistic children.

Meltzer et al. (1975) and Meltzer (1983b) sustain that the autistic patient has a bidimensional mind in which the Ego perceives only the sensory nature of objects. It is a world that makes no room for introjection, where the perception of the object and the sensory quality of its surface are tightly bound and the Self is but a mere sensitive surface. The autistic child breaks the object down into single sensory components and is consequently unable to give meaning to stimuli from the outside world, experienced as bombarding the senses.

Frances Tustin (1986, 1991) described sensory phenomena, her so-called ‘autistic shapes’, which she regarded as the precursors to hallucinations (visual, auditory and so forth). In her view, such phenomena are present in both autistic children and autistic adults. Autistic objects are bizarre creations bearing coarse auto-sensuous properties, and they derive from self-induced body sensations that are stimulated by hard, solid objects such as toy cars or trains.

As can be seen, analytic literature on hallucinations provides differing hypotheses on their origin. These go from the primitive conflictual origin, which leads to denying reality via massive projection onto the outside world (Freud) to hallucinations as the result of a destructive attack on the sense organs (Bion); Lacan saw them as resulting from the dissociation of various mental functions by means of foreclosure and, for Tustin, they originate in a kind of excited, primitive, epidermal perception, similar to that in autistic disorders. They are sensory forms that are unconnected to thought and serve to distance the patient from the anxiety of the void and of non-existence.

A neuroscientific contribution

Advances in neuroimaging mean that brain structure and function can be studied in vivo, thereby paving the way towards new findings in the study of human psychopathology.

The most significant neuroscientific data on hallucinations can be found in ‘The hallucinating brain: A review of structural and functional neuroimaging studies of hallucinations’ (2008) by Paul Allen and colleagues, which gathers together the most important studies from 1990 to 2008. Researchers have observed that, in the absence of brain damage, activation occurs in the brain region that corresponds to the type of hallucination (that is, auditory, visual or tactile). For example, during psychotic episodes with auditory hallucinations, activation was found in Broca’s area (McGuire et al. 2003), involved in speech function; the anterior cingulate gyrus, which plays a role in attentional processes and the temporal cortex, involved in auditory perception and memory; these same areas are inactive when the patient is no longer hallucinating. In addition, the sensory areas that produce hallucinations activate only when the neighbouring language areas activate.

There is therefore verbal preparation of what the patient will express senso-rially during the hallucination (Hoffman et al. 2008). Relevant is the fact that even before the hallucination is produced, intense preparatoiy activity is going on, which is thought to demonstrate the individual’s complete unawareness of his involvement in his disorder. There is a change to brain activity six to nine seconds before the onset of verbal hallucinations in the left inferior frontal cortex, the cingulate cortex and the right middle temporal gyrus. This is believed to demonstrate that the cortical regions mediating internal language prepare hallucinations and activate before those that give rise to hallucinatory perceptions. For several decades this was already known in psychiatry from recordings of neuromuscular activation of the vocal cords and pharyngeal muscles, which activate several seconds before the patient produces the auditory hallucination.

Another interesting finding (David et al. 1996) is that when the subject is hallucinating, the brain regions involved in the hallucinatory phenomenon are engaged and are impermeable to the reception of external stimuli that they normally respond to; external sensory perception and hallucination therefore compete with one another.

As for the complex problem of reality attribution - that is, how the patient assigns reality to stimuli that originate in his mind - neuroscientists believe hallucinations can change the sense of reality due to a complex imbalance between top-down and bottom-up circuits. Bottom-up processes concern sensory information and perceptions that move from the lower to the higher levels of the brain and are more complex than top-down processes, these latter being involved in control and monitoring that process from the higher levels down to the sensory brain regions.

Hallucinations can form due to a malfunction in the top-down system or to a bottom-up dysfunction; this latter is related to hyperactivation in areas of the secondary somatosensory cortex involved in experiencing vivid perceptions in the absence of sensory stimuli. These, together with a top-down impairment, can give rise to hallucinations and delusions. Cortical and subcortical centres that regulate emotions also activate during hallucinations, which would account for high emotional arousal in the hallucinatory phenomenon.

Interesting is Kenneth Hugdahl’s (2009) work on this subject. Using neuroimaging data and a battery of tests, he found a difference between patients who hear inner voices and recognise them as such and those who attribute them to external sources and therefore hallucinate. For example, in subjects who recognise voices as being ‘inner’, the connection between the temporal lobe, where voices are generated, and the prefrontal cortex, implicated in higher cognitive functions, is retained, whereas in psychotic patients with auditory hallucinations, this connection is lost. In the former case, the prefrontal cortex monitors the sensory experience and rightly considers it as coming from inside, not outside. In psychotic hallucinations, therefore, the function of prefrontal cortical regions that assign meaning to our perceptions fail; specifically, these regions help distinguish between what is subjective (created by the imagination) and what appears real (because it comes from the outside) but is not. For the patient, the ‘voices’ are real, whereas for an external observer, they are not true.

The hypothesis that psychosis is a progressive and irreversible dissociated withdrawal from the world could perhaps find support from neuroscientific studies that can account for the neurobiological bases of this process, which involves a change to connections between perceptual brain regions and those of thought. In the course of the hallucinatory process, sensory perceptual brain regions become hyperactive, and higher functions, whose task it is to monitor the judgement of reality, are hypofunctional. Therefore, in order to produce hallucinations and dominate the rest of the personality, the psychotic process must inhibit higher functions and simultaneously activate sensory perceptual regions. As Kenneth Hugdahl and colleagues have shown, when the connection with prefrontal regions remains intact, voices are not projected externally but are perceived as internal.

I believe that there must be a similar disconnection during sleep, when the higher cortical functions, whose task is to assign meaning to the individual's experience, and the purely sensory ones that are monitored by the former, lose contact with one another. As a result of this connection being lost, the dream seems real to the dreamer, who, however, understands it as something dreamt upon awakening as the connection between the upper and lower functions is restored. In the psychotic hallucinatory process and in the delusion, given that the disconnection persists, the two perceptions - that of the dream and that of the awake state -cannot be compared, as would normally occur. From a neurobiological viewpoint, this is the difference between a dream and a delusion. It also explains why the dream can be interpreted and therefore transformed, but the delusion, encoded as a real fact, is stubbornly fixed.

The mind’s eyes

Psychosis develops via a gradual process of regression in which the individual disinvests from relational psychic reality and withdraws into his own personal, bodily and sensory space. The contrast is not between external and internal reality but between psychic reality and sensory reality, the latter developing at the expense of the former in psychosis. This leads one to think that, in order to create the psychotic process, mental functioning must be restricted, the more evolved functions being locked out so that they can no longer give real meaning to the surrounding world and our psychic experience.

In order to do this, the patient must disconnect himself from cognitive brain functions that discriminate between what is created internally and what exists outside him. This process, to a limited extent, could be at the base of autosuggestion.

ranging from milder to almost hallucinatory forms. During the psychotic episode, the patient lives in a dimension within his body that hostilely separates him from the rest of the world.

The patient ‘feels’ thoughts but cannot think them. When the higher functions, located in the prefrontal lobes, are inhibited, attention towards the outer and relational world narrows, shrinking the individual’s mental space. An important phenomenon is that during hallucination, sensory areas involved in this process are always engaged, meaning that messages from the outside world cannot be received.

The appearance of hallucinations bears witness to a psychic withdrawal that has developed to the extreme, where preformed inner reality gets exteriorised with all its contents of anxiety and violence. The reality of the delusional experience is so because the patient uses his mind’s ‘eyes and ears’; in other words, his mind internally builds an image, which it then ‘sees' externally. Since hallucinations have a ‘sensory' and concrete quality, they can easily deceive the patient as they are similar to perceptions that, under normal conditions, describe the surrounding world. Put differently, visual hallucinations arise from seeing with the mind’s ‘eyes’ and auditory hallucinations from hearing with the mind's ‘ears’.

This is the case of one of my patients who felt persecuted by a group of enemies plotting to kill him. For a long time, his sessions were filled with anxiety-laden descriptions in minute detail of all this criminal organisation’s diabolic actions; the patient was convinced that his enemies had installed microphones and surveillance cameras in his home to monitor his every move. Since he insistently spoke of this hard fact, I asked him to bring one of the video cameras to the session so that we could look at it together, but he said that this was impossible as the video cameras were so tiny that they were virtually invisible. When I asked how he was able to see them, he told me that he saw them with his mind's eyes.

In the hallucinatory state, spatio-temporal organisation and self/outer-world differentiation are obliterated; fantasy loses its ‘as-if’ quality of the imagination and becomes concrete thought. Psychotic hallucinations are of a specific nature, differing from all other mental states: they take shape in close connection with the delusion, which usually occurs first, and once they appear, the psychotic process goes from an ideative delusional level to one that is more specifically sensory. The hallucinatory symptom originates in such clear and indisputable sensory perceptions that any recourse to normal experiences that confirm reality would be in vain. In other words, hallucinations are ‘prepared’ by the psychotic part that seduces and intimidates the patient.

Perceval (Bateson 1961), an author/patient who wrote an account of his illness after his recovery, illustrated with particular clarity his gradual departure from the hallucinatory world. Perceval remembered that towards the end of his confinement in an asylum, as he began to recover from his psychosis, he managed to distance himself from the ‘voices’ that for many years had dominated and tormented him. Often these ‘voices’ originated in his body: in his wheezy breathing, for instance. One day, while listening to a voice that was speaking to him, he realised that it vanished if he focused his mind on something external to him; if instead he recreated the same absence of mind, he went back to hearing the voice. He realised too that his breathing was clad in hallucinated words and sentences, especially when he was agitated. These accurate observations led him to conclude that the voices originated in his head, even though they seemed to come from above, from the air or from the ceiling cornice. Perceval came to understand that hallucinating and directing attention towards the outer world were antagonistic: if the former prevailed, the latter vanished; acknowledging the existence of the outer world deprives the hallucinatory fantasy of its power. Therefore, in order to create the hallucinatory state, it would seem that a mental state of submissiveness is needed.

My clinical hypothesis is that hallucinatory phenomena are the result of a distorted use of the mind practised over a long period by the psychotic outside his awareness: instead of being a tool for relating with others - that is, an organ of knowledge - the mind is employed to create a sensory world dominated by a special, regressive type of pleasure. And this is how the primitive infantile withdrawal into the world of sensory fantasies is created. Naturally, this is not the only process through which the illness is produced, but I believe it is a principal one.

Usually the psychotic hallucinatory experience is positive and seducing in the beginning, with gentle, charming voices, but it then changes, with critical, contemptuous and terrifying voices coming onto the scene, and the state of grandiosity gradually turns into a condition of persecution.

One of my psychotic patients said that before his breakdown and consequent hospitalisation, he, unlike his friends, had been able to get high endogenously without taking drugs. Later, however, this ‘pleasant alienating' operation turned into a terrifying world for him. What occurs during the psychotic process is that the newly created sensory reality begins to nm out of control at a certain point, dominating and invading the healthy part of the personality; auditory or visual hallucinations become malevolent, and delusions of grandeur turn into persecutory states.

We have seen how neuroscientists using neuroimaging techniques have been able to document what happens at a neurophysiological (brain) level when the psychotic process advances in the psyche (mind). The psychosis conquers the mind because it disables discriminatory functions of thought, located mainly in the prefrontal regions, paralysing them in the process. A psychotic sensory withdrawal - that is, a tool capable of cancelling reality - results. The patient can stay in the sensory withdrawal only if he inhibits the brain centres that assign reality and receive emotional input from the environment; thought functions are replaced by sensory perceptions so that the world perceived by the patient is kept within sensory channels whose expansion gives the appearance of the entire world, separateness between inner and outer being lost in the process. Said differently, sensory stimuli do not reach the cognitive centres where they could be analysed and filtered but are ‘held’ in sensory areas, where they dilate and are employed autistically.

That hallucinations and delusions in the psychotic patient result from using the mind as a sensory organ is indirectly demonstrated by the positive effect of psychotropic drugs, which reduce or stop the sensory production of the psychotic mind: hence, their necessity when treating psychotic symptoms.

Thanks to research findings in the field of neuroscience, we now know that mental transformations in psychosis are reflected in changes to the neurobiologi-cal substrate. This terrain shows a body-mind encounter in the form of one single interface. I am of the idea that, as opposed to speaking of a biological base, it might be more fitting to conceive mental illness as being biologically mediated.

From my perspective, psychosis may be considered a bio-psychological transformation, a psychosomatic illness in which the ‘mind’ is able to bring about transformations to its biological substrate, the brain. In this regard, neuroscientific findings concerning changes to sensory brain structures and connections between various regions, when stimulated or when active during a hallucination, represent important acquisitions that help us to establish a link between clinical symptomatology, subjective experience and the neurobiological substrate.

The psychotic illness is the result of a transformational process that involves the whole personality: human relations and awareness of the self, body and mind are annihilated. Once set in motion, the transformation is difficult to stop because it presents itself to the patient as a stimulating enhancement of perceptions and self-awareness.

In this connection, Bion (1967) wrote:

The patient feels imprisoned in the state of mind he has achieved, and unable to escape from it because he feels he lacks the apparatus of awareness of reality which is both the key to escape and the freedom itself to which he would escape.

(p. 39)

This means that when the psychotic patient becomes prisoner of his hallucinatory and delusional experiences, he no longer has at his service the apparatus for consciousness of reality that could help him rebuild his real identity.


1 This chapter draws on subjects of a paper I published with Davalli, Giustino and Per-gami in the International Journal of Psychoanalysis, 96(2): 293-318 (2015). The text here has been summarised and changed somewhat.

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