Short Report Psychopathology 2014;47:270–273 DOI: 10.1159/000358065
Received: May 24, 2013 Accepted after revision: December 12, 2013 Published online: February 12, 2014
A Short Note on Pseudohallucinations Mark A. Turner Department of Community Mental Health, Catterick Garrison, UK
Abstract Pseudohallucinations are poorly understood, with clinicians continuing to rely on historical contributions to inform their views. There have been a number of recent attempts to develop a phenomenologically adequate theory of psychotic symptoms, yet the reciprocal dependence between the structure of such theories and the understanding of pseudohallucinations remains unexploited. This paper seeks to progress the debate about the nature of pseudohallucinations whilst simultaneously providing implicit support for a new two-factor theory of psychotic symptoms by relating the important historical contributions by Hare and Jaspers to the contemporary debate about the aetiology of psychotic symptoms. It will be argued that the focus of Hare and Jaspers on abnormal experience and vivid imagination have their respective analogues in recent theories of psychotic symptoms. It will be suggested, however, that an adequate theory requires a contribution from both processes and that this suggests that there are two types of pseudohallucinations. The paper implies that the concept of pseudohallucination is central to relating aetiological to phenomenological considerations and concludes by drawing out some of
© 2014 S. Karger AG, Basel 0254–4962/14/0474–0270$39.50/0 E-Mail [email protected] www.karger.com/psp
the implications of the proposals for understanding pseudohallucinations involving insight and complex psychotic symptoms. © 2014 S. Karger AG, Basel
Hare and Abnormal Experience
It is 40 years since Edward Hare published ‘A Short Note on Pseudohallucinations’ in the British Journal of Psychiatry in which he argued that they are ‘subjective sensory experiences which are the consequence of functional psychiatric disorders and which are interpreted in a non-morbid way by the patient’ [1]. Hare’s account of pseudohallucinations seems straightforward; however, if pseudohallucinations involve the correct interpretation of abnormal experience, a fortiori hallucinations must involve the incorrect interpretation of abnormal experience, and this is more controversial. In order to understand why, we need to appreciate the close relationship between Hare’s views and recent empiricist theories of delusions, according to which abnormal experiences give rise to delusional hypotheses which are not rejected because they are ‘defectively evaluated’ [2]. The main difficulty with a theory of delusions which relies on abnormal experience and defective evaluation Dr. Mark A. Turner, MBChB, MRCP, FRCPsych, MA, MSc, MPhil, PhD Department of Community Mental Health Duchess of Kent Barracks, Catterick Garrison North Yorkshire DL9 4DF (UK) E-Mail mark.turner73 @ btinternet.com
Downloaded by: UCSF Library & CKM 128.218.166.245 - 5/14/2015 4:45:27 PM
Key Words Phenomenology · Psychosis · Jaspers · Insight
Pseudohallucinations
Jaspers and Vivid Imagination
Before we set out the details of an alternative, we can unravel the confusion which underlies the search for an understanding of pseudohallucinations, and indeed of psychotic symptoms more generally, by examining Jaspers’ views, which were expounded 100 years ago in General Psychopathology and are in many way the historical antithesis of Hare’s. With this in mind, Jaspers [8] supports ‘a clear distinction between sense-phenomena and the phenomenon of imagery (i.e. between hallucination and pseudo-hallucination)’ and conceives of pseudohallucinations, not like Hare, as sense-phenomena, but rather as a form of ‘vivid imagery’. Now Jaspers’ contribution captures an important strand of thought about the aetiology of psychotic symptoms, although its relevance is somewhat obscured by the fact that he drove a theoretical wedge between pseudohallucinations and hallucinations, which makes it difficult to explain the transition between to two states – as Jaspers himself may have recognised and Fish [9] certainly did. The important point, however, is that Jaspers approaches pseudohallucinations from precisely the opposite direction to Hare, i.e. ‘top down’ as opposed to ‘bottom up’ [10]. It should come as no surprise, therefore, that just as Hare’s focus on abnormal experience shows his approach to be related to empiricist theories, Jaspers’ focus on the imagination also has an analogue in the recent literature on the aetiology of psychotic symptoms. Currie and Ravenscroft [11] have argued, in fact, that psychotic symptoms arise when ‘perception-like imaginings’ are misidentified due to an ‘autonoetic agnosia’. Autonoetic agnosia, which here serves a similar function to empiricism’s ‘defective evaluation’, essentially involves an inability to recognise an internally generated event as such and is more familiarly employed to explain auditory hallucinations and passivity phenomena. Currie’s proposals lend themselves to a natural account of pseudohallucinations as Jasperian vivid imagery and, in terms of explaining frank psychotic symptoms, complex contents cause no difficulties. As Walton [12] points outs, ‘imagining is… a free, unregulated activity, subject to no constraints save whim, happenstance, and the obscure demands of the unconscious…’ However, Currie’s account is not without its difficulties and we shall point to just two: first, Currie has no way of accounting for the obvious role of abnormal experiences in the generation of psychotic symptoms, most notably somatoparaphrenic symptoms. A careful analysis of these symptoms suggests in fact that the imagination constitutes a Psychopathology 2014;47:270–273 DOI: 10.1159/000358065
271
Downloaded by: UCSF Library & CKM 128.218.166.245 - 5/14/2015 4:45:27 PM
is that whilst it may provide a way of distinguishing between those phenomena which are of interest to psychiatry and those which are not, it cannot account for how complex psychotic content arises [3]. This is perhaps not surprising as the theory was originally formulated to explain monosymptomatic delusions, and whilst it is not obviously implausible to suggest that believing one’s spouse is an imposter is due to the defective evaluation of an abnormal experience, it is difficult to see how the content of a related but more complex delusion that one’s husband is the son of Adam and Eve [4] could be exclusively experiential. Some empiricists have sought to rely on cognitive bias to take up the explanatory slack, but the difficulties with this suggestion are that not all psychotic individuals exhibit cognitive bias and the approach in any case risks collapsing the explanation of psychotic symptoms with that of medically unexplained symptoms [5]. In terms of understanding where this relates to pseudohallucinations, note that if the only thing standing between pseudohallucinatory content and a frank psychotic symptom is a process which does not contribute to content (i.e. evaluation), then all psychotic content becomes both experiential and potentially pseudohallucinatory. In other words, Hare’s empiricism, when viewed in a broader context, would appear to be committed to the view that even the most bizarre psychotic contents could have pseudohallucinatory counterparts. However, the fact that David [6] refers to a ‘schizophrenic patient who felt he had an actual power station inside him, complete with labourers, machinery, cooling towers, etc., knew it was impossible yet was sure it was so’ suggests that Hare’s difficulty is likely to relate to placing too much aetiological emphasis on experience, rather than the implicit countenancing of complex pseudohallucinations. The issues are obviously complex, and aetiological considerations quickly become entangled with those relating to phenomenology and insight. It is perhaps not surprising, then, that Berrios [7], whose work on the subject of pseudohallucinations is amongst the most thought provoking, decides that the concept is ‘irretrievably fuzzy and needs to be abandoned’. However, ‘fuzziness’ or vagueness is not necessarily a reason for ceasing to use a concept, especially if, as we shall see, much of the fuzziness can be dissolved by reappraising the historical contributions in light of recent theories of psychosis. What we require is an understanding of pseudohallucinations which is underwritten by an adequate theory of psychotic symptoms, and if Hare and empiricism cannot provide this, then we will need to look elsewhere.
Two Types of Pseudohallucinations
On the one hand, we require a theory of psychotic symptoms with content generating mechanisms which can explain how complex psychotic symptoms arise and, on the other, we need to accommodate the close relationship between abnormal experience and psychotic symptoms. We also require that our theory can give a natural account of pseudohallucinations, and preferably one which can respect the insights of both Hare and Jaspers on the subject. With these and a number of other theoretical constraints in mind, Turner [3] argues that such a theory can be formulated by retaining abnormal experience as a first factor and replacing the defective evaluation and/or cognitive bias second factor with confabulation. Following Johnson et al. [14], Turner further argues, and this is where we see the precise relevance of Jaspers’ work on pseudohallucinations, that confabulation involves ‘a propensity to detailed imagination’ and defective monitoring. The advantages of Turner’s proposal over rival accounts are significant and before outlining the implications for our understanding of pseudohallucinations we will pause to outline several of the more obvious ones. First, the new theory allows the empiricist notion of defective evaluation to be recast as ‘defective monitoring’, thereby avoiding the implication that there is, as David [6] once put it, ‘an insight centre’ in the brain, whilst at the same time showing the relevance of defective integrated awareness to psychosis. Second, the theory opens up a natural account of the failures of acting and reasoning on delusions (and indeed, of generation of impossible psychotic contents which David [6] drew attention to) which have troubled empiricist accounts and threatened their central tenet that delusions are beliefs. This brings us to pseudohallucinations and to the way in which the new proposals are able to impose some order on what was previously ‘fuzzy’ and demonstrate the importance of the concept by facilitating a rapprochement between Hare and Jaspers. With this in mind, what the theory implies is that there may in fact be two types of pseudohallucinations, corresponding to the experiential and imaginational components of the theory. The first type would be ‘Hare pseudohallucinations’ involving 272
Psychopathology 2014;47:270–273 DOI: 10.1159/000358065
content which is experiential and leading to, for example, rudimentary auditory and visual phenomena. The second type would be ‘Jasperian pseudohallucinations’ involving imaginational content. Further clarification of the nature of Jasperian pseudohallucinations will need to accommodate the fact that the imagination is a complex faculty with both imagistic and propositional capabilities both of which may be affected by defective monitoring. However, it is imagistic imaginations that involve ‘vivid imagery’ and in the absence of defective monitoring these can be equated to Jasperian pseudohallucinations. It is important to note that for reasons developed in detail by Turner [3], imagistic and propositional imaginations which are defectively monitored amount, conceptually, to confabulations, and that propositional imaginings which are not defectively monitored are closely related to pseudologia fantastica. The latter involve imaginations about counterfactual states of affairs which an individual can either present as merely imaginations or, for reasons beyond the scope of this discussion, as true. The issues are subtle, but the following comments by Fish [9], although ostensibly about ‘fantastic illusions’, bring out the conceptual relationships between propositional and imagistic imaginations, confabulations and pseudologia fantastica: ‘Professor Fish who insisted that during the interview he saw the psychiatrist’s head change into that of a rabbit. This patient was given to exaggeration and confabulation. He also would invent non-existent puppies and tell other patients not to tread on the puppy’.
Insight, Complex Symptoms and ‘Hare-Jaspers’ Pseudohallucinations
Clinicians will recall case discussions in which no clear attempt is made to delineate questions about the characteristics of pseudohallucinations from questions about insight, and to separate both from the implicit assumptions about the phenomenological possibilities related to individual diagnoses. The latter is a highly complicated matter which will not be discussed in this paper. However, the postulation of two types of pseudohallucinations, each with their own distinct aetiology, should serve as a starting point for preventing contributors talking about two different types of pseudohallucinations without realising it. Instead, the focus can shift immediately to deciding which of the two types of pseudohallucinations most appropriately captures the phenomenology of an individual case. Jasperian pseudohallucinations should Turner
Downloaded by: UCSF Library & CKM 128.218.166.245 - 5/14/2015 4:45:27 PM
‘secondary or reparative effort’, as Hundert [13], referring to Minkowski, puts it. Currie’s second difficulty is that his theory collapses the distinction between psychotic symptoms and confabulations at a conceptual level.
‘lack concrete reality and appear in inner subjective space’ [8], whereas Hare pseudohallucinations should be less complex and have more prominent sensory, including spatial, characteristics. Interesting as such debates promise to be, can we rely on assumptions about the capabilities of experience and the imagination and characteristics of their products to distinguish between pseudohallucinations and hallucinations, especially in light of the aforementioned nosological issues? Fish [9] implies not when he refers to ‘patients with substantial hallucinations which occur in outer space, but which they recognise as the result of their active, vivid imagination’. Hare [1] goes further when he writes: ‘from a psychiatric view, the experience of a sensation is less important than the way in which the subject interprets it’. Hare is arguing that insight should serve as the final arbiter of the distinction between pseudohallucinations and hallucinations, and he would surely be correct if symptom content were entirely experiential. However, for a theory which holds that most symptom content is imaginational matters are not so simple and a reliance on insight leads hallucinations and delusions to be classified with conceptual confabulations – imagistic and propositional, respectively.
Perhaps we should accept a degree of misclassification as individuals with schizophrenia confabulate and at least Hare and Jasperian pseudohallucinations are correctly classified. The difficulty, however, comes from the other direction: David’s case with the ‘power station’ delusion ‘knew it was impossible yet was sure it was so’, and this suggests that if we use insight as the determining factor, then some complex symptoms will have to be classified as pseudohallucinations. Fortunately, our two-factor theory can accommodate this if we extend the suggestion that the processes which give rise to psychotic symptoms can dissociate from one another and give rise to their own symptoms. We have already argued that these will include Hare pseudohallucinations (abnormal experiences), Jasperian pseudohallucinations (vivid imaginations) and conceptual confabulations (imagistic and propositional). However, perhaps it is possible for there to be a third type of pseudohallucination, a ‘Hare-Jaspers’ pseudohallucination, comprising both abnormal experiences and imaginations without defective monitoring; if so, this would suggest that the concept of pseudohallucination is central to our understanding of cases involving complex contents in which a feeling of conviction and a sense of truth come apart.
References
Pseudohallucinations
6 David AS: Insight and psychosis. Br J Psychiatry 1990;156:798–808. 7 Berrios G: The History of Mental Symptoms: Descriptive Psychopathology since the Nineteenth Century. Cambridge, Cambridge University Press, 1996. 8 Jaspers K: General Psychopathology. Baltimore, Johns Hopkins University Press, 1997, vol 1. 9 Fish F: Clinical Psychopathology: Signs and Symptoms in Psychiatry. Bristol, Wright, 1974. 10 Bayne T, Pacherie E: Bottom-up or top-down: Campbell’s rationalist account of monothematic delusions. Philos Psychiatr Psychol 2004;11:1–11.
11 Currie G, Ravenscroft I: Recreative Minds. Oxford, Oxford University Press, 2002. 12 Walton K: Mimesis as Make-Believe. Cambridge, Harvard University Press, 1990. 13 Hundert EM: Philosophy, Psychiatry and Neuroscience: Three Approaches to the Mind. A Synthetic Analysis of the Varieties of Human Experience. Oxford, Clarendon Press, 1990. 14 Johnson MK, O’Connor M, Cantor J: Confabulation, memory deficits and frontal dysfunction. Brain Cogn 1997;34:189–206.
Psychopathology 2014;47:270–273 DOI: 10.1159/000358065
273
Downloaded by: UCSF Library & CKM 128.218.166.245 - 5/14/2015 4:45:27 PM
1 Hare EH: A short note on pseudo-hallucinations. Br J Psychiatry 1973;122:469. 2 Coltheart M, Langdon R, McKay R: Schizophrenia and monosymptomatic delusions. Schizophr Bull 2007;33:642–647. 3 Turner MA: Psychosis, agnosia and confabulation: an alternative two factor account. Cogn Neuropsychiatry 2014;19:116–133. 4 Cutting J: Clinical Psychopathology: Two Worlds – Two Minds – Two Hemispheres. Oxford, Oxford University Press, 1997. 5 Turner MA: Factitious disorders: reformulating the DSM-IV diagnostic criteria. Psychosomatics 2006;47:23–32.
Received: May 24, 2013 Accepted after revision: December 12, 2013 Published online: February 12, 2014
A Short Note on Pseudohallucinations Mark A. Turner Department of Community Mental Health, Catterick Garrison, UK
Abstract Pseudohallucinations are poorly understood, with clinicians continuing to rely on historical contributions to inform their views. There have been a number of recent attempts to develop a phenomenologically adequate theory of psychotic symptoms, yet the reciprocal dependence between the structure of such theories and the understanding of pseudohallucinations remains unexploited. This paper seeks to progress the debate about the nature of pseudohallucinations whilst simultaneously providing implicit support for a new two-factor theory of psychotic symptoms by relating the important historical contributions by Hare and Jaspers to the contemporary debate about the aetiology of psychotic symptoms. It will be argued that the focus of Hare and Jaspers on abnormal experience and vivid imagination have their respective analogues in recent theories of psychotic symptoms. It will be suggested, however, that an adequate theory requires a contribution from both processes and that this suggests that there are two types of pseudohallucinations. The paper implies that the concept of pseudohallucination is central to relating aetiological to phenomenological considerations and concludes by drawing out some of
© 2014 S. Karger AG, Basel 0254–4962/14/0474–0270$39.50/0 E-Mail [email protected] www.karger.com/psp
the implications of the proposals for understanding pseudohallucinations involving insight and complex psychotic symptoms. © 2014 S. Karger AG, Basel
Hare and Abnormal Experience
It is 40 years since Edward Hare published ‘A Short Note on Pseudohallucinations’ in the British Journal of Psychiatry in which he argued that they are ‘subjective sensory experiences which are the consequence of functional psychiatric disorders and which are interpreted in a non-morbid way by the patient’ [1]. Hare’s account of pseudohallucinations seems straightforward; however, if pseudohallucinations involve the correct interpretation of abnormal experience, a fortiori hallucinations must involve the incorrect interpretation of abnormal experience, and this is more controversial. In order to understand why, we need to appreciate the close relationship between Hare’s views and recent empiricist theories of delusions, according to which abnormal experiences give rise to delusional hypotheses which are not rejected because they are ‘defectively evaluated’ [2]. The main difficulty with a theory of delusions which relies on abnormal experience and defective evaluation Dr. Mark A. Turner, MBChB, MRCP, FRCPsych, MA, MSc, MPhil, PhD Department of Community Mental Health Duchess of Kent Barracks, Catterick Garrison North Yorkshire DL9 4DF (UK) E-Mail mark.turner73 @ btinternet.com
Downloaded by: UCSF Library & CKM 128.218.166.245 - 5/14/2015 4:45:27 PM
Key Words Phenomenology · Psychosis · Jaspers · Insight
Pseudohallucinations
Jaspers and Vivid Imagination
Before we set out the details of an alternative, we can unravel the confusion which underlies the search for an understanding of pseudohallucinations, and indeed of psychotic symptoms more generally, by examining Jaspers’ views, which were expounded 100 years ago in General Psychopathology and are in many way the historical antithesis of Hare’s. With this in mind, Jaspers [8] supports ‘a clear distinction between sense-phenomena and the phenomenon of imagery (i.e. between hallucination and pseudo-hallucination)’ and conceives of pseudohallucinations, not like Hare, as sense-phenomena, but rather as a form of ‘vivid imagery’. Now Jaspers’ contribution captures an important strand of thought about the aetiology of psychotic symptoms, although its relevance is somewhat obscured by the fact that he drove a theoretical wedge between pseudohallucinations and hallucinations, which makes it difficult to explain the transition between to two states – as Jaspers himself may have recognised and Fish [9] certainly did. The important point, however, is that Jaspers approaches pseudohallucinations from precisely the opposite direction to Hare, i.e. ‘top down’ as opposed to ‘bottom up’ [10]. It should come as no surprise, therefore, that just as Hare’s focus on abnormal experience shows his approach to be related to empiricist theories, Jaspers’ focus on the imagination also has an analogue in the recent literature on the aetiology of psychotic symptoms. Currie and Ravenscroft [11] have argued, in fact, that psychotic symptoms arise when ‘perception-like imaginings’ are misidentified due to an ‘autonoetic agnosia’. Autonoetic agnosia, which here serves a similar function to empiricism’s ‘defective evaluation’, essentially involves an inability to recognise an internally generated event as such and is more familiarly employed to explain auditory hallucinations and passivity phenomena. Currie’s proposals lend themselves to a natural account of pseudohallucinations as Jasperian vivid imagery and, in terms of explaining frank psychotic symptoms, complex contents cause no difficulties. As Walton [12] points outs, ‘imagining is… a free, unregulated activity, subject to no constraints save whim, happenstance, and the obscure demands of the unconscious…’ However, Currie’s account is not without its difficulties and we shall point to just two: first, Currie has no way of accounting for the obvious role of abnormal experiences in the generation of psychotic symptoms, most notably somatoparaphrenic symptoms. A careful analysis of these symptoms suggests in fact that the imagination constitutes a Psychopathology 2014;47:270–273 DOI: 10.1159/000358065
271
Downloaded by: UCSF Library & CKM 128.218.166.245 - 5/14/2015 4:45:27 PM
is that whilst it may provide a way of distinguishing between those phenomena which are of interest to psychiatry and those which are not, it cannot account for how complex psychotic content arises [3]. This is perhaps not surprising as the theory was originally formulated to explain monosymptomatic delusions, and whilst it is not obviously implausible to suggest that believing one’s spouse is an imposter is due to the defective evaluation of an abnormal experience, it is difficult to see how the content of a related but more complex delusion that one’s husband is the son of Adam and Eve [4] could be exclusively experiential. Some empiricists have sought to rely on cognitive bias to take up the explanatory slack, but the difficulties with this suggestion are that not all psychotic individuals exhibit cognitive bias and the approach in any case risks collapsing the explanation of psychotic symptoms with that of medically unexplained symptoms [5]. In terms of understanding where this relates to pseudohallucinations, note that if the only thing standing between pseudohallucinatory content and a frank psychotic symptom is a process which does not contribute to content (i.e. evaluation), then all psychotic content becomes both experiential and potentially pseudohallucinatory. In other words, Hare’s empiricism, when viewed in a broader context, would appear to be committed to the view that even the most bizarre psychotic contents could have pseudohallucinatory counterparts. However, the fact that David [6] refers to a ‘schizophrenic patient who felt he had an actual power station inside him, complete with labourers, machinery, cooling towers, etc., knew it was impossible yet was sure it was so’ suggests that Hare’s difficulty is likely to relate to placing too much aetiological emphasis on experience, rather than the implicit countenancing of complex pseudohallucinations. The issues are obviously complex, and aetiological considerations quickly become entangled with those relating to phenomenology and insight. It is perhaps not surprising, then, that Berrios [7], whose work on the subject of pseudohallucinations is amongst the most thought provoking, decides that the concept is ‘irretrievably fuzzy and needs to be abandoned’. However, ‘fuzziness’ or vagueness is not necessarily a reason for ceasing to use a concept, especially if, as we shall see, much of the fuzziness can be dissolved by reappraising the historical contributions in light of recent theories of psychosis. What we require is an understanding of pseudohallucinations which is underwritten by an adequate theory of psychotic symptoms, and if Hare and empiricism cannot provide this, then we will need to look elsewhere.
Two Types of Pseudohallucinations
On the one hand, we require a theory of psychotic symptoms with content generating mechanisms which can explain how complex psychotic symptoms arise and, on the other, we need to accommodate the close relationship between abnormal experience and psychotic symptoms. We also require that our theory can give a natural account of pseudohallucinations, and preferably one which can respect the insights of both Hare and Jaspers on the subject. With these and a number of other theoretical constraints in mind, Turner [3] argues that such a theory can be formulated by retaining abnormal experience as a first factor and replacing the defective evaluation and/or cognitive bias second factor with confabulation. Following Johnson et al. [14], Turner further argues, and this is where we see the precise relevance of Jaspers’ work on pseudohallucinations, that confabulation involves ‘a propensity to detailed imagination’ and defective monitoring. The advantages of Turner’s proposal over rival accounts are significant and before outlining the implications for our understanding of pseudohallucinations we will pause to outline several of the more obvious ones. First, the new theory allows the empiricist notion of defective evaluation to be recast as ‘defective monitoring’, thereby avoiding the implication that there is, as David [6] once put it, ‘an insight centre’ in the brain, whilst at the same time showing the relevance of defective integrated awareness to psychosis. Second, the theory opens up a natural account of the failures of acting and reasoning on delusions (and indeed, of generation of impossible psychotic contents which David [6] drew attention to) which have troubled empiricist accounts and threatened their central tenet that delusions are beliefs. This brings us to pseudohallucinations and to the way in which the new proposals are able to impose some order on what was previously ‘fuzzy’ and demonstrate the importance of the concept by facilitating a rapprochement between Hare and Jaspers. With this in mind, what the theory implies is that there may in fact be two types of pseudohallucinations, corresponding to the experiential and imaginational components of the theory. The first type would be ‘Hare pseudohallucinations’ involving 272
Psychopathology 2014;47:270–273 DOI: 10.1159/000358065
content which is experiential and leading to, for example, rudimentary auditory and visual phenomena. The second type would be ‘Jasperian pseudohallucinations’ involving imaginational content. Further clarification of the nature of Jasperian pseudohallucinations will need to accommodate the fact that the imagination is a complex faculty with both imagistic and propositional capabilities both of which may be affected by defective monitoring. However, it is imagistic imaginations that involve ‘vivid imagery’ and in the absence of defective monitoring these can be equated to Jasperian pseudohallucinations. It is important to note that for reasons developed in detail by Turner [3], imagistic and propositional imaginations which are defectively monitored amount, conceptually, to confabulations, and that propositional imaginings which are not defectively monitored are closely related to pseudologia fantastica. The latter involve imaginations about counterfactual states of affairs which an individual can either present as merely imaginations or, for reasons beyond the scope of this discussion, as true. The issues are subtle, but the following comments by Fish [9], although ostensibly about ‘fantastic illusions’, bring out the conceptual relationships between propositional and imagistic imaginations, confabulations and pseudologia fantastica: ‘Professor Fish who insisted that during the interview he saw the psychiatrist’s head change into that of a rabbit. This patient was given to exaggeration and confabulation. He also would invent non-existent puppies and tell other patients not to tread on the puppy’.
Insight, Complex Symptoms and ‘Hare-Jaspers’ Pseudohallucinations
Clinicians will recall case discussions in which no clear attempt is made to delineate questions about the characteristics of pseudohallucinations from questions about insight, and to separate both from the implicit assumptions about the phenomenological possibilities related to individual diagnoses. The latter is a highly complicated matter which will not be discussed in this paper. However, the postulation of two types of pseudohallucinations, each with their own distinct aetiology, should serve as a starting point for preventing contributors talking about two different types of pseudohallucinations without realising it. Instead, the focus can shift immediately to deciding which of the two types of pseudohallucinations most appropriately captures the phenomenology of an individual case. Jasperian pseudohallucinations should Turner
Downloaded by: UCSF Library & CKM 128.218.166.245 - 5/14/2015 4:45:27 PM
‘secondary or reparative effort’, as Hundert [13], referring to Minkowski, puts it. Currie’s second difficulty is that his theory collapses the distinction between psychotic symptoms and confabulations at a conceptual level.
‘lack concrete reality and appear in inner subjective space’ [8], whereas Hare pseudohallucinations should be less complex and have more prominent sensory, including spatial, characteristics. Interesting as such debates promise to be, can we rely on assumptions about the capabilities of experience and the imagination and characteristics of their products to distinguish between pseudohallucinations and hallucinations, especially in light of the aforementioned nosological issues? Fish [9] implies not when he refers to ‘patients with substantial hallucinations which occur in outer space, but which they recognise as the result of their active, vivid imagination’. Hare [1] goes further when he writes: ‘from a psychiatric view, the experience of a sensation is less important than the way in which the subject interprets it’. Hare is arguing that insight should serve as the final arbiter of the distinction between pseudohallucinations and hallucinations, and he would surely be correct if symptom content were entirely experiential. However, for a theory which holds that most symptom content is imaginational matters are not so simple and a reliance on insight leads hallucinations and delusions to be classified with conceptual confabulations – imagistic and propositional, respectively.
Perhaps we should accept a degree of misclassification as individuals with schizophrenia confabulate and at least Hare and Jasperian pseudohallucinations are correctly classified. The difficulty, however, comes from the other direction: David’s case with the ‘power station’ delusion ‘knew it was impossible yet was sure it was so’, and this suggests that if we use insight as the determining factor, then some complex symptoms will have to be classified as pseudohallucinations. Fortunately, our two-factor theory can accommodate this if we extend the suggestion that the processes which give rise to psychotic symptoms can dissociate from one another and give rise to their own symptoms. We have already argued that these will include Hare pseudohallucinations (abnormal experiences), Jasperian pseudohallucinations (vivid imaginations) and conceptual confabulations (imagistic and propositional). However, perhaps it is possible for there to be a third type of pseudohallucination, a ‘Hare-Jaspers’ pseudohallucination, comprising both abnormal experiences and imaginations without defective monitoring; if so, this would suggest that the concept of pseudohallucination is central to our understanding of cases involving complex contents in which a feeling of conviction and a sense of truth come apart.
References
Pseudohallucinations
6 David AS: Insight and psychosis. Br J Psychiatry 1990;156:798–808. 7 Berrios G: The History of Mental Symptoms: Descriptive Psychopathology since the Nineteenth Century. Cambridge, Cambridge University Press, 1996. 8 Jaspers K: General Psychopathology. Baltimore, Johns Hopkins University Press, 1997, vol 1. 9 Fish F: Clinical Psychopathology: Signs and Symptoms in Psychiatry. Bristol, Wright, 1974. 10 Bayne T, Pacherie E: Bottom-up or top-down: Campbell’s rationalist account of monothematic delusions. Philos Psychiatr Psychol 2004;11:1–11.
11 Currie G, Ravenscroft I: Recreative Minds. Oxford, Oxford University Press, 2002. 12 Walton K: Mimesis as Make-Believe. Cambridge, Harvard University Press, 1990. 13 Hundert EM: Philosophy, Psychiatry and Neuroscience: Three Approaches to the Mind. A Synthetic Analysis of the Varieties of Human Experience. Oxford, Clarendon Press, 1990. 14 Johnson MK, O’Connor M, Cantor J: Confabulation, memory deficits and frontal dysfunction. Brain Cogn 1997;34:189–206.
Psychopathology 2014;47:270–273 DOI: 10.1159/000358065
273
Downloaded by: UCSF Library & CKM 128.218.166.245 - 5/14/2015 4:45:27 PM
1 Hare EH: A short note on pseudo-hallucinations. Br J Psychiatry 1973;122:469. 2 Coltheart M, Langdon R, McKay R: Schizophrenia and monosymptomatic delusions. Schizophr Bull 2007;33:642–647. 3 Turner MA: Psychosis, agnosia and confabulation: an alternative two factor account. Cogn Neuropsychiatry 2014;19:116–133. 4 Cutting J: Clinical Psychopathology: Two Worlds – Two Minds – Two Hemispheres. Oxford, Oxford University Press, 1997. 5 Turner MA: Factitious disorders: reformulating the DSM-IV diagnostic criteria. Psychosomatics 2006;47:23–32.
