Hallucinations

Hallucinations [from Latin (h)al(l)ucinatio--deception], relate to the so-called 'deceptions of the senses' and represent a disorder of that psychical process which underlies all our representations of the external world, namely--the process of perception. Already under conditions of normal functioning of the sense organs, imaginary and incorrect perceptions of various orders can arise: ringing in the ears, sparks before the eyes, phenomena of light refraction, double vision, etc. Such imaginary and distorted perceptions are usually recognized as such; they are elementary, do not disturb the correct perception of actual sensations, and therefore are not classified as deceptions of the senses in the strict sense of the term. The latter term is applied to such imaginary or erroneous perceptions in which the subject receives a sensation of an effect on the sense organ from without and projects it into the external world. If there is actual irritation present, but reaching consciousness in a perverted, distorted form, then such deceptions of the senses are called illusions (see); but if there is no object present that serves as the source of perception, then there is H. The division of deceptions of the senses into illusions and H. since the time of the French psychiatrist Esquirol is generally accepted in psychiatry, but to a certain extent is conditional, since it is not always possible to draw a strict boundary between H. and illusions: first, in H., not only in the area of poorly differentiated sensations of smell, taste, touch, but also with respect to the higher senses--vision and hearing, it is impossible to completely exclude the presence of weak external irritations; second, in illusions, on the other hand, there is always a hallucinatory element. From true psychosensory H., it is necessary to distinguish the so-called 'psychic' H. (Baillarger), or 'pseudohallucinations,' first described and studied in detail by Kandinsky. Pseudohallucinations, like H., can possess great brightness, but, unlike H., they lack the character of reality and corporeality, are not projected into external space, but are perceived by the subject within himself: 'with the inner ear,' 'with the mental eye,' etc. Pseudohallucinatory phenomena represent, as it were, the result of a hallucinatory process that has not reached in its development the limit of true H., which is why they are proposed to be called incomplete H. or hallucinoids (for more details--see Pseudohallucinations). Types of hallucinations. H. are divided, naturally, first of all according to the sense organs: into visual, auditory, olfactory, gustatory, tactile, muscular and general sense, and those connected with sensations in internal organs. Visual hallucinations occur either in the form of simple, elementary phenomena: sparks, fire, spots, or in the form of indistinctly outlined objects--shadows, silhouettes, hazy figures, or appear with all the brightness, plasticity and complexity characteristic of real things. Visual deceptions, more than any other H., are subject to control by other senses, mainly, touch; therefore they are usually short-lived, rare during the day and in conscious patients, but easily seize patients in delirious and twilight states. They do not possess the stability and persuasiveness of auditory deceptions, usually do not mix with real impressions with clear consciousness, and are often considered by patients to be artificially produced. The prognostic significance of visual H. is generally not bad. Auditory H. are most frequent and, due to the enormous importance of hearing for higher psychical activity, play an especially important role in psychopathology. Most often they manifest in the form of 'voices,' which can be extremely diverse in quantity, localization, strength, intonation, timbre and especially in content. More often they are of unpleasant content: abusive, reproachful, critical or mocking; often imperative, more rarely--pleasant or encouraging; simultaneous voices of opposite character, arguing with each other, conducting entire dialogues, are not uncommon. The voices discuss the intimate past of the patient, unknown to anyone and often forgotten by him, or, which is especially tormenting, loudly repeat his thoughts (the so-called 'double thinking,' 'Gedankenlautwerden'). Being in close connection with the general content of consciousness, 'voices' are distinguished by special persuasiveness for the patient and exert a very great influence on his behavior. More rarely auditory deceptions manifest in a simpler form (the so-called acousmas)--noise, knocking, ringing, music, etc. Prognostically, auditory H., in contrast to visual ones, are usually unfavorable. Olfactory and gustatory H. rarely occur independently and are practically difficult to distinguish from each other, since both functions are normally closely connected. They are expressed more often in unpleasant smells (stench, burning, decay, excrement, etc.) and unpleasant taste sensations; much more rarely--in pleasant perceptions. Very rarely is this a matter of true H., more apparently--of illusory perceptions interpreted in a delusory manner, giving the patient reason to think about poisoning, about the mixing of poisonous or unpleasant substances into food, etc. What has just been said applies to an even greater extent to H. in the area of other lower senses: touch, muscular and general sense. In tactile H., sensations of touch, crawling, bites, presence of foreign objects under the skin, etc., are experienced. Deceptions of the muscular sense are expressed in abnormal sensations of excessive lightness or heaviness of the body or surrounding objects or--in involuntary movements of the tongue and other limbs. Deceptions of the general sense represent less H. than interpretations by patients of their sensations: passage of electric current, 'sucking out of the brain,' sexual violation, etc. Such hallucinatory sensations are most common in schizophrenia and have a bad prognostic significance. In addition to division according to sense organs, there are also other types of H. H. are distinguished: simple, i.e., in the area of one of the sense organs, and complex, due to the simultaneous participation of two or more sense organs; unilateral, i.e., developing in one half of the visual field or perceived by one ear, which apparently is connected with central lesions of the nervous system, disrupting its paired function, or with unilateral peripheral lesion of the sense organ; extracampine, when perception is localized outside the visual field (for example, an object is seen by the patient behind the head); hypnagogic, observed in a drowsy state, during the transition from a waking state to sleep; reflex, arising in connection with irritation of another sense organ (for example, visual hallucination following a real auditory sensation); obsessive, developing from obsessive ideas and phobias, and finally, collective hallucinations, or mass hallucinations, experienced, under special conditions, simultaneously by a number of persons. Hallucinations in the mentally ill are observed very often (in 30-80%, according to different authors), with auditory H. being most common, followed in frequency by visual, then cutaneous, olfactory and gustatory ones. Simple H. develop more often than complex ones. In different mental illnesses H. occur with different frequency: in some (delirium tremens, amnesia, dementia paranoides, epileptic and hysterical psychoses) they are very common; in others (manic-depressive psychosis, progressive paralysis) they appear much less frequently; in third (psychasthenia, paranoia) they are almost not observed, and in the same disease significant individual fluctuations in the frequency and quality of H. are noted. Different clinical forms correspond to different characters of H. Auditory H. predominate in schizophrenia and chronic alcoholic forms, with auditory deceptions in schizophrenics usually being accompanied by deceptions of the lower senses, mainly the general sense. Extremely bright visual, as well as auditory H., mainly terrifying, occur in epileptics: patients see fire, shining weapons, hear threats, shots, etc. Visual H. are most characteristic of acute diseases, especially with disturbance of consciousness (amnestic, twilight and delirious states, intoxication psychoses), where visual deceptions predominate, changeable, dreamlike, giving very bizarre experiences. In this respect, the H. in delirium tremens are very characteristic, distinguished by their multiplicity, mobility, brightness (a multitude of moving small animals, insects, fantastic beasts, imps, threads, etc.). Recognition of H. represents a very important, but not always easy task, and, besides questioning, is based on certain objective signs of H., which include peculiarities of behavior, facial expressions, posture and gesticulation of the patient, not in accordance with and dependent on the surrounding conditions. In auditory H., patients listen attentively, answer someone, cover their head, plug their ears with cotton, paper, bread, etc. In visual hallucinations, patients sometimes fix one point, look intently, squint their eyes. Changes in mood, tendency to solitude, unreasoned laughter, whispering, crying, etc., are suspicious in relation to hallucinations. Conditions for the occurrence of H.

Being an intellectual process, predominantly an 'idea projected outward' (Lelut), and being in the closest connection with the entire psychic life of the subject, both conscious and unconscious, hallucinations depend primarily on purely psychological conditions. These include: a) the state of consciousness—narrowing, clouding, dimming of consciousness, weakening or inhibiting the suppressing or corrective activity of consciousness, facilitate the appearance of hallucinations; b) emotions—affective states not only predispose to hallucinations but often also determine their character and content; c) delusional ideas, which are often a source of hallucinations; suggestive influences: fading of hallucinations with a change in environment, suggested hallucinations; d) peripheral irritations, especially prolonged and monotonous: ticking of clocks, fixation of a white surface, etc.; e) absence of normal irritations: silence, deafness, darkness, solitude, imprisonment, etc. As physiological factors in the development of hallucinations, the following are important: physical exhaustion (hunger, debilitating diseases), endogenous and exogenous poisonings—self-poisoning, infections and various intoxications, especially alcohol, opium, morphine, hashish, cocaine. The significance of hallucinations for the behavior of patients is very great, as they often determine the actions of the patient and can lead to the most unexpected actions, sometimes very dangerous for the patient himself or for those around him. Theories of hallucinations. The mechanism and localization of hallucinations remain unclear and controversial, despite the numerous theories proposed to explain the essence of hallucinations and reflecting the state of psychological knowledge at different times. The peripheral theory, the oldest (Calmeil, J. Millet), seeing the cause of hallucinations in abnormal irritation of the peripheral sense organs, has been abandoned by all due to its contradiction to clinical facts: hallucinations in the absence of functions of the peripheral apparatus (in the blind, those who have lost hearing, amputees, etc.). The obvious dependence of hallucinations on the general content of consciousness and the state of the brain led to the creation of the central theory in its various modifications. Meynert, based on the views of his time on the role and relationship of the cerebral cortex and subcortical ganglia (the cortex as the bearer only of representations and the ganglia as centers of sensory perception are in an antagonistic relationship), localized hallucinations in the subcortical centers and considered them the result of the interaction of two conditions: suppression of the activity (pathological condition) of the cortex and excitation of the subcortical nodes. After the discovery of sensory centers in the cortex, Meynert's theory gave way to the cortical theory (Tamburini, Korsakov, Goldstein, Störring, Osipov). Connecting the origin of hallucinations with the cerebral cortex, some authors consider them a consequence of irritation of only the sensory cortical centers, while others attribute them to the simultaneous spread of excitation from the cortex to the periphery, i.e., in the direction opposite to the normal conduction of irritation. Without this latter condition, cortical irritation can give, in their opinion, only pseudohallucinations; for the development of true hallucinations, which have the character of reality and are projected outward, the mentioned reverse excitation of the peripheral apparatus is necessary. Anatomical-clinical work of recent years (Jacob, Gerstmann, Henschen) confirms the cortical localization of hallucinations (damage to the temporal lobes of the cortex in hallucinatory-paranoid states of paralytics, the occipital lobe—in visual hallucinations). Schrottenbach found an elongation of reaction time in hallucinating individuals in those sensory areas in which hallucinations are present. From this, the basic condition for hallucinations is assumed to be a decrease in excitability for external irritations and the associated increase in receptivity for endogenous (somatic) irritations. I. Vvedensky. Hallucinatory confusion, a symptom-complex characteristic of one of the varieties of amnesia (see) and distinguished by the fact that in its picture hallucinatory phenomena come to the forefront. Hallucinatory transformation of perceptions usually begins already at the very beginning of the disease. The surrounding environment begins to seem incomprehensible and mysterious, things—changed, not real, ghostly, and faces—substituted. Everything that happens around acquires special significance, it seems that some extraordinary events are coming: the end of the world, the Last Judgment, etc. Then real hallucinations already appear on the scene, mostly simultaneously visual and auditory, and sometimes olfactory. Patients see fire, fires and ruins, general destruction, hellish flames, terrible monsters, beasts; around are heard cannon shots, thunderclaps, bell ringing, cries and groans, abusive words and threats. Or the patient feels that he has died and is being buried: he sees his relatives, hears crying and conversations about him. Then he with extraordinary speed falls into hell, where they prepare terrible tortures for him, then finds himself transferred to a desert where robbers or wild beasts lie in wait for him, then floats over meadows full of beautiful flowers. Patients often feel that they separate from the ground with extraordinary ease, fly in an airplane or are transported to other planets. Others lead innumerable human masses, wage wars, stage revolutions or become victims of pirates, conspirators and secret assassins. Finally, very painful experiences of endless wanderings through dark underground spaces, sewers, drains, etc., are not uncommon. All these pictures usually quickly and without any sequence replace each other, unfolding against the general emotional background of anxious bewilderment and fear. As in other forms of amnesia, the speech and thinking of patients are incoherent, they cannot collect their thoughts, they are disoriented. Old psychiatrists attributed the confusion and affect of bewilderment to the excessive abundance and rapid change of hallucinatory images, however, the fact that amentive states, occurring without hallucinations, develop against the same unclear consciousness, shows that the basis of confusion lies in direct organic causes (intoxication, circulatory disorders, etc.). Pictures similar to those described represent one of the most common forms of the amentive symptom-complex. Being characteristic of acute infectious and intoxication psychoses, they often develop during individual attacks of schizophrenia and manic-depressive psychosis.

P. Zinoviev.

Painful hallucinations, phenomena of perceiving pain without objective irritation, are observed in persons who have undergone amputation, when the subject experiences pain and other sensations in the absent parts of a non-existent limb. Bright painful hallucinations can be suggested under hypnosis. Painful sensations experienced by patients with hypochondriacal ideas in various organs can also be classified as painful hallucinations.