Hallucinations in the psychotic state: Psychoanalysis and the 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 † Via ‡ Via § Via

Ramazzini 7, 20129 Milano, Italy – [email protected] Cenisio 45, 20154 Milano, Italy – [email protected] Eschilo 8, 20145 Milano, Italy – [email protected] Carlo Poma 18, 20129 Milano, Italy – [email protected]

(Accepted for publication 1 May 2014)

In this contribution, which takes account of important findings in neuroscientific 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 topdown and bottom-up brain circuits. The present authors postulate that hallucinatory phenomena represent the outcome of a psychotic’s 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 fostering 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 mind’s ‘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 subject’s psychic experience. The findings of the neurosciences facilitate understanding of how, in the psychotic 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 psychotic 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 patient’s construction of a withdrawal into a mental–sensory 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 patient’s eyes. Copyright © 2014 Institute of Psychoanalysis

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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 environmental 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 hallucinatory 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 character 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 apparently 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 perceive the figure of his father as real. He was thoroughly convinced that the father’s 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)

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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, however, 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 remembered 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 auditory 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 wishfulfilment in children is also based on this analogy. The earliest psychoanalytic theories linked psychological disorders to corresponding phases of infant development. According to such theories, mental 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: Freud’s 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


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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-Reichmann, 1960; De Masi, 2000, 2006; Hartman, 1953; Jackson, 2001; Katan, 1954; Lacan, 1955–56; Lombardi, 2005; Lucas, 2009; Ogden, 1982, 1989; Pao, 1979; Racamier, 2000; Resnik, 1972; Rey, 1994; Rosen, 1961; Rosenfeld 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 different 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 Schreber (Freud, 1911), he attributed hallucinations to the unconscious conflict arising from Schreber’s unconscious homosexual impulses. In his consideration of regression (Freud, 1915), he noted that in normal circumstances reality testing made it possible to abandon hallucinatory wish-fulfilment, whereas in the psychoses the older mode was reestablished. Elsewhere, Freud (1924) puts forward the interesting hypothesis that psychotic reality stems from the patient’s own bodily sensations, through the confusion of proprioceptive with exteroceptive reality. He now postulates 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.




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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 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 [. . .].

However, psychotic hallucinations, included in delusional systems, are here also attributed to memories of the past that seek to emerge from oblivion, 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 boundary, which separates conscious from unconscious. In his view, the boundary of the ego is ultimately a kind of sense organ that automatically distinguishes what is real from what is unreal. If for any reason the ego’s 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 recathexis of the object by the ego – Federn considers it to be a consequence of the falsification of reality and of the loss of the ego’s 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 hallucinosis 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 Copyright © 2014 Institute of Psychoanalysis



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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 (1955–56). In his view, the structuring of psychosis is the outcome 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 distinguishes 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 subject’s personality will therefore present itself as an experience 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 distinguishes the acute phase from the sub-acute phase of the psychosis. In the sub-acute or chronic phase the acoustic hallucination protects against the ego’s 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 former’s 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 twodimensional 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 involving crude autosensuality. Autistic objects are self-induced bodily sensations and the product of autosensual activities, but are stimulated by Int J Psychoanal (2014)



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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 hallucinations, which are equivalent, in her view, to Tustin’s autistic shapes and Meltzer’s zonal fixations – the starting point for directional reversal 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, hallucinations 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, epidermal, 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 principal neuroscientific findings on hallucination are set out in a contribution by Paul Allen et al. (2008) entitled The hallucinating brain: A review of structural 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 hallucinations. In the absence of brain damage, particular areas of the brain corresponding 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 Broca’s area (the seat of language), of the anterior cingulate gyrus (responsible for attention processes), and of the temporal cortex (in charge of auditory perception and memory). 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 imperCopyright © 2014 Institute of Psychoanalysis


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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 ‘bottom–up’ circuits, given that the neuronal circuits operate by top–down and bottom–up processing.1 The bottom–up processes concern sensory information or perceptions that travel from lower to higher levels of the brain, the latter being characterized by greater complexity. These higher centres hold the previously acquired expectations and notions that monitor the incoming data in the top–down 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 subcortical functions. Resting-state hyperactivity of the regions involved in the generation of hallucinations is an indication of what Allen et al. (2008) call ‘over-perceptualization’: an abnormal or increased bottom–up 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 top–down system – that is, of the structures responsible for the control and monitoring of the sensory zones from above. Bottom–up dysfunction takes the form of hyperactivation 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 attention: 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 bottom–up modality. Attention in this case has not been determined by knowledge 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 identifies the object he is seeking when he sees it. This is an example of the top–down mode of information use. In other words, in a purposive action, top–down processing (guided conceptually) and bottom–up processing (guided by the senses) interact.




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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 resting state changes and stimulus-induced activity. The authors hypothesize that the abnormal rest–rest interaction may be confused (or taken) by the brain with rest–external 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, rest–rest 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 hallucinations that occur, how often they occur, and whether they are contextually 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, hallucinatory 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, anxietyladen 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.



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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 difference 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 experience 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 hallucinations 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 neuroscientific 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 perception of self and of one’s 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 information 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 Int J Psychoanal (2014)



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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 correspond to individual classes of objects. Hence perception results from the brain’s 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 hypotheses 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 simulation 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 neuroscientific findings, sensation has increasingly come to be regarded as an important 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 emotional 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, sensory experience differs in meaning according to the meeting of emotional state (top–down) and sensory stimulus (bottom–up). If the emotional/affective state predominates, the sensory stimulus is recorded in a relational context 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 Copyright © 2014 Institute of Psychoanalysis


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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 sensory 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 tolerated 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 reminiscent 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; O’Shaughnessy, 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 pathological organization into which an individual withdraws in order to avoid relating to the world and experiencing the associated anxieties. According to Steiner, a psychic retreat is quite stable in character and may persist throughout life. Int J Psychoanal (2014)



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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 regression of the personality, but also radically transform it, sometimes even generating 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 knowledge, their psychotic counterparts-to-be proceed in the opposite direction, withdrawing mentally into a world of gratifying sensory fantasies that separate 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 personality that is destined later to colonize the healthy part and create the psychotic pathology. In the case of psychosis, the withdrawal or the equilibrium 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 autoerotism; 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. Freud’s idea was developed 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 Copyright © 2014 Institute of Psychoanalysis


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psychic retreat. Freud’s insight remains useful for understanding certain aspects of the psychotic state, such as, for example, the detachment from emotional reality, withdrawal into the subject’s 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 personality, as occurs, for instance, in infantile sexual trauma. In psychic withdrawal, 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 prevalence 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 patient’s 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 withdrawal 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 psychotic’s 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 sensory 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 patient’s 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 ‘pleasurable alienation’ had distanced him from contact with reality and the hallucinatory 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 delusions of grandeur turn into persecutory states. Int J Psychoanal (2014)



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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 clinical examples show, although the mode of entry into the psychotic world differs 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 auditory 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 thoroughly 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 cornice of the ceiling of the room [. . .] (Bateson, 1961, p. 294f.)

It is interesting to note Perceval’s 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).



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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 countertransference 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 crying 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 contact, 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 analyst: “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 can’t 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 world’s ferocity, as the animal is impaled on the horn of a rhinoceros. Berta sometimes uses a doll representing a male figure as if it were a ball: she shapes it, throws it, and deliberately avoids catching it in flight. “I’ve 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 patient’s 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 situations tend to return in the hallucinations of disfigured little girls.




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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 door’s locked . . . the fiend has locked it” . . . “What an absolutely ugly face . . . his eyes are red . . . it’s dark . . . you can’t 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 wandering up and down the stairs: “They are two little girls dressed in white who make absolutely sure you can’t see their faces – perhaps because they’re 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 hallucinations (of a persecutory and imperative nature), severe behavioural disturbances, 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 criminals). The voices had then become particularly threatening, with the intervention 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 hallucinations, 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.




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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 hallucinations 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 hallucination he had on waking from a particularly anxiety-laden, persecutory dream. A severed wolf’s 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 wolf’s 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. It’s a hallucination. I’ve 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 people’s 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 auditory 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 alluding to his insanity. On one occasion he described a hallucinatory attack (involving the usual comment “He’s 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).




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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 “people’s” 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 people’s thoughts, which subsequently became hallucinatory attacks).

The mind–body 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 brain’s 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 judgement 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 cortical functions, responsible for assigning meaning to an individual’s experience, 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 Blechner’s (2005) patient is highly instructive in this connection.



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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 Wernicke’s area and Broca’s area in auditory hallucinations. Whereas the former area generates hallucinations, the latter activates the vocal musculature, the activation being detectable by electromyography 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 individual 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 autosuggestion, 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 functions (for which the prefrontal lobes are responsible) are inhibited, the patient’s attention to the external, relational world is reduced and his mental space is restricted. An important phenomenon in hallucination is that the sensory areas on which the hallucinatory process is centred remain occupied, 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 demonstrate what happens on the neurophysiological level (that of the brain) as the psychotic process progresses in the psyche (the mind). The psychosis overcomes the mind because it deactivates and paralyses the faculties of discrimination 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 sensory retreat only by inhibiting the operation of the brain centres essential to emotional reception of the environment and to the judgement of reality. Int J Psychoanal (2014)



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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 delusion 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 hallucinatory 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 identity. 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 disappearance 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 emotional 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 possible biological foundation of psychosis and of the complex relationship Copyright © 2014 Institute of Psychoanalysis


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between mind and brain. In particular, on the basis of important neuroscientific 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 connection between clinical symptoms, subjective experience, and the neurobiological 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 Vergleich. In diesem Beitrag untersucht der Autor unter Ber€ ucksichtigung wichtiger Erkenntnisse der Neurowissenschaften wie auch der psychoanalytischen Forschung die Bedeutung der tiefreichenden Verzerrungen, die das mit halluzinatorischen Ph€anomenen einhergehende psychische Funktionieren begleiten. Neurowissenschaftliche Studien belegen, dass Halluzinationen den Realit€atssinn infolge komplexer Ver€ anderungen des Verh€altnisses zwischen Top-down- und Bottom-up-Schaltkreisen des Gehirns verzerren. Die Autoren des Beitrags postulieren halluzinatorische Ph€anomene als Ergebnis der l€angerfristigen, 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 F€allen nicht als Organ der Erkenntnis oder als Instrument zur Vertiefung zwischenmenschlicher Beziehungen benutzt. Der halluzinierende Psychotiker zieht die Besetzung der psychischen (relationalen) Realit€at zur€ uck und isoliert sich in seinem pers€ onlichen, k€ orperlichen und sensorischen Raum. Die polaren Realit€aten betreffen nicht allein Außen 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 s€amtlicher 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 K€ orperorgans, in diesem Fall des Gehirns, ver€andern kann.




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tico. Contribuciones al Psicoana lisis de las NeurocienLas Alucinaciones en el Estado Psico cias. En esta contribuci on, que toma en cuenta algunos hallazgos importantes en las investigaciones neurocientıficas y tambien psicoanalıticas, los autores exploran el significado de las distorsiones profundas del funcionamiento psıquico que ocurren en los fen omenos alucinatorios. Los estudios neurocientıficos han establecido que las alucinaciones distorsionan el sentido de la realidad debido a una alteraci on compleja del equilibrio entre los circuitos cerebrales arriba–abajo y abajo–arriba. Los autores postulan aquı que los fen omenos alucinatorios representan el resultado del uso distorsionado de la mente que hace el psic otico, durante un perıodo 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 parrgano de conocimiticular de placer regresivo. En estos casos, por lo tanto, la mente no se utiliza como o ento ni como un instrumento para fomentar las relaciones con los demas. El psic otico que esta alucinando decatectiza la realidad psıquica (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 tambien psıquica versus sensorial. Por lo tanto, se podrıa decir que las alucinaciones visuales se originan a partir de ver con los ‘ojos’ de la mente, y las alucinaciones auditivas a partir de oır con los ‘oıdos’ de la mente. En estas condiciones, se restringe el funcionamiento mental, anulando las funciones mas maduras, que ya no pueden asignar un significado real al mundo circundante ni a la experiencia psıquica del sujeto. Los hallazgos de las neurociencias facilitan la comprensi on de c omo, en el proceso alucinatorio rgano somatico, en este caso, el cerebro. psıc otico, la mente puede modificar el trabajo de un o tat psychotique. La comparaison entre la psychanalyse et les neurosciences. Hallucinations et e Dans cet article qui rend compte des decouvertes importantes de la recherche dans le champ des neurosciences et celui de la psychanalyse, les auteurs explorent la signification des distorsions profondes du fonctionnement psychique qu’on observe dans les phenomenes hallucinatoires. Les etudes neuroscientifiques ont montre que les hallucinations deformaient le sens de la realite en raison d’une alteration complexe de l’equilibre entre les circuits cerebraux top–down et bottom–up. Les auteurs de cet article postulent que les phenomenes hallucinatoires resultent chez les psychotiques d’une 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 n’est pas utilise en tant qu’organe de connaissance, ni comme un instrument permettant d’entrer en relation avec les autres. Le psychotique hallucinant desinvestit la realite psychique (relationnelle) et se retire dans un espace personnel, corporel et sensoriel qui lui est propre. Les realites qui s’opposent 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 l’esprit et les hallucinations auditives comme etant issues des « oreilles » de l’esprit. 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 l’experience psychique du sujet. Les decouvertes des neurosciences facilitent la comprehension de la facßon dont, dans le processus hallucinatoire psychotique, l’esprit parvient a modifier le fonctionnement d’un 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 significato 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 dell’equilibrio dei circuiti cerebrali dall’alto verso il basso e dal basso verso l’alto. Gli autori ipotizzano che i fenomeni allucinatori rappresentino l’esito di un uso distorto, prolungato nel tempo, che lo psicotico fa della propria mente. Nello stato allucinatorio la parte psicotica della personalit a non usa le mente come organo di conoscenza o strumento per relazionarsi con gli altri ma per produrre 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 sensoriale. Il contrasto non e` tra realta` esterna e realta` interna, come e` stato spesso sostenuto, bensı` 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 condizioni, 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 all’esperienza psichica del soggetto. Le scoperte delle neuroscienze aiutano a comprendere come, nel processo allucinatorio psicotico, la mente arrivi a modificare il funzionamento di un organo somatico come il cervello.



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