Patients Described
PERSISTING HALLUCINATIONS FOLLOWING CHILDHOOD SEXUAL ABUSE Terry Heins, Allison Gray and Maxine. Tennant
Hallucinations can persist for many years after childhood sexual abuse. If we recognise this, we will not mis-diagnose psychosis and we may treat with psychotherapy (talk). The hallucinations are distinct from hallucinations in schizophrenia though patients havefrequently been given that diagnosis. They would generally be classified as pseudo-hallucinations. They are generally self-referential. They can involve all sensory modalities. Three case reports illustrate this link. Methods for interviewing and providing ongoing help are discussed. Issues in phenomenology and diagnosis are considered. Posttraumatic stress disorder is the best diagnostic fit, though psychotic depression may explain some cases. Freud’s case of Frau P (1896) was an early report of this link. Australian and New Zealand Journal of Psychiatry 1990; 24561-565 Persisting hallucinations following childhood sexual abuse have been extensively documented by Ellenson, an American psychiatric social worker. He reported on forty female incest survivors aged sixteen to fifty years seen at a community mental health clinic[ I]. Incest was defined as sexual contact between a child and an adult who violated a position of trust, authority or caretaking. Careful mental state examinations found that all showed a post-incest syndrome involving specific disturbances in thought (certain types of nightmares, obsessions, dissociative experiences and phobias) and in perception (certain types of illusions and visual and auditory hallucinations). He suggested the syndrome might be unique to incest survivors and therefore might predict such a history. He found that the few women who had some ~~~
Phillip Health Centre, Corinna Street, Phillip, ACT Terry Heins FRANZCP, Child Psychiatrict Allison Gray BSW, Social Worker Maxine Tennant FRANZCP. Conwltant Psychiatrist Corre\pond with Dr Hein\
of these features but no recall of incest at the time of interview all reported non-sexual physical abuse. In a subsequent article Ellenson gave more details of the unusual disturbances in perception[2]. Commonest were shadowy figures, movements in peripheral vision, intruder sounds, persecutory voices, directive voices and inner helper voices. Much less frequent were tactile, kinaesthetic, somatic and olfactory hallucinations. These disturbances do not fit any single syndrome. Post traumatic stress disorder provides the best fit. Psychotic depression could be considered in some cases. In an older era these patients would have likely been diagnosed as suffering from some type of hysteria. They are unlikely to have a schizophrenic illness. Since alerted by Ellenson’s articles, we have broadly confirmed these findings in more than ten patients. We must have sometimes missed the significance of childhood sexual abuse in the past. We wish to draw this possible association to the attention of Australian clinicians so that it can be tested by a wider body of
Downloaded from anp.sagepub.com at Virginia Tech on March 14, 2015
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experience. If the link is confirmed it will be valuable information for the many survivors of serious childhood sexual abuse.
casereports Three case reports will illustrate long persisting hallucinations following childhood sexual abuse. Case 1 : Maureen aged 55 presented to a community health centre in a suicidal state two months after her husband died of cancer. On most days since adolescence she had experienced voices making critical comments about her, e.g. “slut”, “whore”, “never make it”. The voices, two male and one female, were not recognised from her life experiences. One of the male voices gave positive messages. She called the most persistent critical voice “Harry”. For many years she had understood that “the voices were not real” and “they are inside my head”. She could gain short term control of the voices with talking reassuringly to herself, putting on loud music or telephoning a friend. Her father had been critical and physically abusive when she was a child; “he did all sorts of things”. When child sexual abuse was queried she veered off the topic but later acknowledged repeated frequent sexual abuse from age eight to late adolescence. Her recall was incomplete. As a young child she was forced to watch her parents having intercourse. Vaginal intercourse with her father occurred frequently, about monthly, from age eight. Around age eleven she was raped several times by a cousin seven years older. At fifteen her father encouraged her younger brothers to have intercourse with her. At sixteen she had an abortion of a pregnancy resulting from one of these incestuous relationships and the sexual abuse largely ceased. On her first unchaperoned date at nineteen she was raped. She married at twenty one and moved out of her parents’ district. She had four children. Maureen had had five psychiatric admissions between 18 and 35 years of age. Summaries have been obtained from the hospitals. All record auditory hallucinations and all diagnose schizophrenia. There was no family history of any psychoses. Maureen was experiencing “flashbacks” (her word), vivid visual memories of being raped by her father as a girl. These had often recurred throughout her adult life but were currently intense as she was frequently visiting her father, now in his eighties, dying in a nursing home “hoping he would say he was sorry”. He only continued his derogatory criticism. She had never previously disclosed the
sexual abuse and welcomed a chance to share the story over several meetings with a female counsellor. Subsequently she shared the experiences with her younger sister. Her mother had sent this sister away to boarding school at age eight and she was probably not a victim. Case 2: Amanda, aged 22, married with one child, presented stating her husband had sent her saying she was crazy and needed fixing. She was acutely anxious as for many years she had believed herself to be mad and feared she would be committed to a mental hospital. O n two previous occasions she had seen psychiatrists but had been unable to talk of the hallucinatory experiences that were worrying her. For many years she had experienced a harsh male voice inside her head, most often when she tried to sleep. This voice accused her of doing “dirty sexual things” and of being wicked and worthless. At night she was often very anxious and at times when by herself she would feel someone was watching her. She was afraid to undress at night and slept in her clothes. She mentioned that her older sister always slept wrapped in a rug even on the hottest of nights. In later sessions she revealed that she had felt worse since the birth of her daughter. She was afraid of being alone with the baby for fear she would sexually assault the child. She had difficulty changing the child’s nappy for fear of hurting the child. She thought people were watching her as they believed she was a sexual pervert, who would attack the baby. At this point she was asked when she had been sexually assaulted. She became acutely distressed, cried and finally said that she had been sexually assaulted by her father for a number of years since she was very young. Her sister had also been sexually assaulted. As a teenager she had been raped on two occasions and had been left feeling guilty that she had somehow allowed it to happen. She had never previously discussed her sexual experiences. Sharing was very difficult and she continually blamed herself. Her mother had a history of manic depressive illness and had often been in hospital. Her father was an alcoholic, who was at times physically violent. With counselling the hallucinatory experiences have ceased and she no longer regards herself as mad, though her self image is still very low. Gradually she is learning to handle and relate to her child. She still accepts a relationship with an alcoholic husband who verbally abuses her, seeing him as being good to their child and valuing the support and acceptance she gets from his family. Case 3: Nathan was 15 when referred by his school counsellor concerned about his serious depression. He
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TERRY HEINS, ALLISON GRAY, MAXINE TENNANT
had made a suicide attempt at a school camp one month previously. He was an excellent student and very articulate. He was markedly depressed and was seen for individual meetings. After several weeks trust was sufficient for him to speak about “the fish people”. These mermaid-like creatures would appear when he was alone, seeming to be opposite or beside him and on one occasion as if walking along the street with him. They were not clearly male or female. They recurringly told him that he was “sleazy”, “no good” and “useless” and “should kill himself ’. The deeper his depressed state the more frequently he experienced these hallucinations. He had been sexually abused by an uncle at several family gatherings between seven and eight years of age. He had suffered rectal bleeding on most of these occasions. This was first revealed to his family when he was interviewed by police after he had been raped by a man at age fourteen. His depression worsened and several months later he was admitted to a psychiatric unit. An initial diagnosis of schizophrenia was made by the inpatient psychiatrist and he was given anti-psychotic drugs with no benefit. However there were no features of schizophrenia apart from the hallucinations. The diagnosis was revised to depression and he was discharged on anti-depressant medication. His mood slowly improved over several weeks. As his mood lifted he was less troubled by his hallucinations. His end of year school grades were very poor. One year later he has regained academic success, but has had recurring spells of moderate depression. The hallucinations appeared to resolve as he shared the experiences of sexual abuse with a female fellow student and with a male teacher. He made more limited disclosures to his school counsellor. For a time he wrote of the abuse experiences in a journal but stopped when this was discovered by his mother. Her reaction was extreme and rejecting. More recently he has been writing poetry that alludes to the abuse.
Discussion Typically there is a strong tendency to avoid the pain andembarrassment of discussing the past abuse. When the abuse is recalled, victims rarely connect their present d e p r e s s i o n , perceptual disturbances, headaches, anger outbursts or other symptoms with the past abuse. Instead a common fear is that they are in fact going crazy. When the abuse is disclosed, it is
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unusual to reveal perceptual disturbances[2]. The clinician needs to gently and methodically ask about these things. Useful questions include: Do you have nightmares or night terrors? What happens in your bad dreams? Do the same dreams recur? Are the dreams consistently completed or are they left unfinished? Do you ever smell things that trigger memories or feelings? Do you ever see or notice odd things? At home? When alone? When the bedroom door is closed? Do you ever hear things, particularly when alone, such as a child in distress, footsteps’? Do you ever have odd bodily sensations or feelings such as someone touching you? Transition points in psychosexual development are risk periods for abused people when symptoms and the issues are likely to resurface: puberty, dating, forming a more stable relationship, marriage, the birth of a child, a child or grandchild reaching the age at which abuse occurred or illness or death of the abuser. Hallucinations have been variously subdivided. The commonest subdivision is on perceived source of origin. True hallucinations are vivid and whole false perceptions, that are perceived as out there in the world, while pseudo-hallucinations are pathological images experienced as emanating from the mind, which are not under voluntary control[3,41. Most of these hallucinatory experiences experienced by these patients are correctly described as pseudo-hallucinations. A second subdivision is on elaborateness. Elementary hallucinations are vague, fleeting and illdefined. The vast majority of hallucinations reported by Ellenson were elementary[2]. Complex hallucinations are prolonged, detailed and vivid. Ellenson found elaborate recurring hallucinations were associated with secondary drug abuse and particularly with prolonged or vicious sexual abuse that began in early childhood.
Diagnosis The presence of hallucinations in these cases causes diagnostic confusion. Most doctors have learnt to link hallucinations with psychotic conditions, functional and organic. However hallucinations do occur in nonpsychotic conditions; in manifestations of ‘hysterical’ illness and if a traumatic experience in childhood fractures basic trust. Under current psychiatric classification all of these cases would be best initially diagnosed as Posttraumatic Stress Disorder (DSM-III-R1[5]. They meet
Downloaded from anp.sagepub.com at Virginia Tech on March 14, 2015
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the criteria of; A. The person has experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone, e.g., serious threat to one’s life or physical integrity ... B. The traumatic event is persistently re-experienced in at least one of the following ways: ... ( 3 ) sudden acting o r feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative [flashback] episodes, ... C. Persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness (not present before the trauma) ... D. Persistent symptoms of increased arousal (not present before the trauma) ... In all cases depression was prominent and in each the depression may have at times reached a psychotic degree. However psychotic depression does not seem a sufficient explanation. The hallucinatory experiences, while present at times of marked depression, also recurred without current major mood disturbance. Earlier psychiatric classifications had categories for conditions lying in the borderland between psychotic and non- psychotic conditions, which might have been applied to such patients. Psychogenic psychosis is a diagnosis long used by European psychiatrists(61. Hysterical psychosis was advocated by Hollander and H irsc h[ 71. Although hysteria has long lost favour as a diagnostic model it is interesting to recall how late nineteenth century writing on hysteria emphasised hallucinations. The hallucinatory phase (attitudes passinnelles) was the third of four phases in Charcot’s theory of hysteria[8]. The observations of Freud and Breuer tended to confirm this phase of Charcot: “Where this is present in a well marked form, it exhibits the hallucinatory reproduction of a memory which was important in bringing on the onset of the hysteria - the memory either of a single major trauma or a series of interconnected part-traumas (such as underlie common hysteria)”. 191
Evidence for a link with childhood sexual abuse A link between persisting hallucinations and childhood sexual abuse remains an inference from accumulated clinical cases. No comprehensive studies following up sexually abused children or even focussed surveys of adult patients with hallucinations have been done.
Freud is currently criticised for misnaming his patients’ accounts of childhood sexual abuse as “infantile sexual experiences”[ lo]. However in his early work he certainly recognised this link with persisting hallucinations[ 1 11. Frau P, a thirty two year old woman with “chronic paranoia”, had visual hallucinations of naked females and male genitals for several months. She heard voices that she did not recognise, commenting on her actions with threats and reproaches. She had no formed persecutory delusions. Psychoanalysis was broken off when she developed “severe hallucinations which had all the signs of dementia praecox” requiring care in an institution. However she recovered, had another child and showed no signs of psychosis over fifteen years, according to a note added in 1922 to a later edition. Freud linked her hallucinations to “the brother and sister had for years been in the habit of showing themselves to one another naked before going to bed ...I then succeeded in getting her to reproduce the various scenes in which her sexual relationship with her brother (which had certainly lasted at least from her sixth to her tenth year) had culminated ...these hallucinations were nothing else than parts of the content of repressed childhood experiences”. The final conclusion reached by Freud was that the subject’s claims of sexual abuse could have been a product of their fantasy. We have carefully considered whether such an explanation might apply to the cases we have seen. However we are convinced that the abuse did occur, substantially as recounted by these people. There is some corroboration by others, as when Maureen’s younger sister was sent to boarding school at eight and Nathan’s parents knew of rectal bleeding. That these hallucinations largely resolved with sharing and clarification seems further evidence that the sexual abuse in childhood really occurred. How specific is any link between childhood sexual abuse and these persisting hallucinations? The evidence is not clear. Ellenson has argued that these hallucinations are “unique to, and shared by, adult female incest survivors regardless of other clinical or demographic differences”[2]. However childhood sexual abuse is common[ 121 and persisting hallucinations are not rare. A broad association has been documented between childhood sexual abuse and adult psychiatric disorder in general. Sexual abuse in childhood is reported by 55%[ 13) and 46%[ 141 of adult female psychiatric inpatients. Case reports have
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TERRY HEINS, ALLISON GRAY, MAXINE TENNANT
described schizophreniform psychoses in adolescent mentally retarded girls following sexual assault[ 151. Case reports suggest childhood sexual abuse may precipitate multiple personality disorder[ 161. At the present time, when the extent and effects of childhood sexual abuse are just beginning to be adequately discussed there is some risk of seeing spurious links. However the numbers of case reports seem sufficient to draw this possible association to the attention of Australian clinicians. If the link between childhood sexual abuse and persisting hallucinations is anywhere near as specific as Ellenson has claimed, then a retrospective survey of current patients with persisting hallucinations should be a valuable next step, despite its relative methodological weakness. Any attempt to clarify this possible association further will have to dissect the broad category of childhood sexual abuse. It is probable that inappropriate or premature sexual experience of itself is not a sufficient causal factor of subsequent disorder. Most psychiatrists would know of cases of apparently benign transient sexual relationships among siblings. Anthropological studies describe cultures where sexual experimentation is not necessarily pernicious[lO]. Other causal factors are likely to be the breach of trust or the violence or seduction or confusion surrounding the experience, the continuing shame and guilt and the subsequent loss of the years of support in adolescence that would normally have come from the perpetrator. These questions will be difficult to answer in studies of groups but they are crucial in individual cases to plan sensitive treatment.
Ongoing help Our own clinical experience has convinced us of the high return from specific enquiry for childhood sexual abuse. The relief people experience, when their experiences can be shared in a supportive relationship resembles the relief that often follows enquiries about suicidal intent or sexual orientation. Starting to deal with the past abuse can be a very powerful and frightening time for the victim and family. The dissociation has protected himher from distressing memories, that are untenable within their system of values, and from the rage and guilt. Victims may fear expression of anger will lead to loss of control. Others seem influenced by an unacknowledged childhood worry that they will be punished for expressing their feelings. The family may not tolerate expression of
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anger particularly if the abuse is current or recent. Strengthening the bond between non-offending parent or parents and the child is crucial. Acknowledgement of what has happened and support assists resolution of anger, grief and depression. Sharing and clarifying the traumatic events over several meetings appears to have assisted all of the cases reported. Hallucinations have become less preoccupying and much less frequent.
Ellenson GE. Detecting a history of incest: a predictive syndrome. Social Casework: The Journal of Contemporary Social Work 1985; 66:525-532. Ellenson GE. Disturbances of perception in adult female incest survivors. Social Casework: The Journal of Contemporary Social Work 1986; 67: 149- 160. Mullen PE. The mental state and states of mind. In: Hill P, Murray R, Thorley A, eds. Essentials of Postgraduate Psychiatry. 2nd ed. London: Grune and Stratton, 1986: 3-36. Hare EH. A short note on pseudo-hallucinations. British Journal of Psychiatry 1973; 122:469-476. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Third Edition, Revised. Washington, DC, American Psychiatric Association, 1987, pp 247-25 I . Stromgren E. Psychogenic psychoses. In: Hirsch SR, Shepherd M. eds. Themes and Variations in European Psychiatry. Bristol: Wright, 1974. Hollander MH, Hirsch SJ. Hysterical psychosis. American Journal of Psychiatry 1964; 120:1066-74. Charcot J-M. Isolation in the Treatment of Hysteria In: Clinical Lectures on Diseases of the Nervous System, trans. Savill T, London: New Sydenham Society, 1889,cited In: Veith 1. Hysteria: The History of a Disease. Chicago: University of Chicago Press, 1965, p 212. 9. Breue; J, Freud S. The Psychical Mechanism of Hysterical Phenomena( 1893). In: Jones E. ed. Collected Papers of Sigmund Freud. Vol I, 24-41, London: Hogarth, 1950. 10. Ward E. Freud and the legacy of mind binding. pp 100- 117, In Father-Daughter Rape. London: The Women’s Press, 1984. 1 1. Freud S. (111) A case of chronic paranoia In: Further remarks on the neuro-psychoses of defence 1896 translated In: Jones E. ed. Collected Papers of Sigmund Freud, Vol 1. London: Hogarth, 1950, pp 174-183. 12. Kosky R. Incest: What do we really know about it? Australian and New Zealand Journal of Psychiatry 1987; 21:430-440. 13. Bryer BB, Nelson BA, Miller JB, Krol PA. Childhood sexual and physical abuse as factors in adult psychiatric illness. American Journal of Psychiatry 1987: 144: 1426- 1430. 14. Beck JC, van der Kolk B. Reports of childhood incest and current behavior of chronically hospitalized psychotic women. American Journal of Psychiatry 1987; 144: 1474-1476. 15. Varley CK. Schizophrenifom psychoses in mentally retarded adolescent girls following sexual assault. American Journal of Psychiatry 1984; 141:593-595. 16. Ament A. Rape and multiple personality disorder. American Journal ofpsychiatry 1987; 144541.
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PERSISTING HALLUCINATIONS FOLLOWING CHILDHOOD SEXUAL ABUSE Terry Heins, Allison Gray and Maxine. Tennant
Hallucinations can persist for many years after childhood sexual abuse. If we recognise this, we will not mis-diagnose psychosis and we may treat with psychotherapy (talk). The hallucinations are distinct from hallucinations in schizophrenia though patients havefrequently been given that diagnosis. They would generally be classified as pseudo-hallucinations. They are generally self-referential. They can involve all sensory modalities. Three case reports illustrate this link. Methods for interviewing and providing ongoing help are discussed. Issues in phenomenology and diagnosis are considered. Posttraumatic stress disorder is the best diagnostic fit, though psychotic depression may explain some cases. Freud’s case of Frau P (1896) was an early report of this link. Australian and New Zealand Journal of Psychiatry 1990; 24561-565 Persisting hallucinations following childhood sexual abuse have been extensively documented by Ellenson, an American psychiatric social worker. He reported on forty female incest survivors aged sixteen to fifty years seen at a community mental health clinic[ I]. Incest was defined as sexual contact between a child and an adult who violated a position of trust, authority or caretaking. Careful mental state examinations found that all showed a post-incest syndrome involving specific disturbances in thought (certain types of nightmares, obsessions, dissociative experiences and phobias) and in perception (certain types of illusions and visual and auditory hallucinations). He suggested the syndrome might be unique to incest survivors and therefore might predict such a history. He found that the few women who had some ~~~
Phillip Health Centre, Corinna Street, Phillip, ACT Terry Heins FRANZCP, Child Psychiatrict Allison Gray BSW, Social Worker Maxine Tennant FRANZCP. Conwltant Psychiatrist Corre\pond with Dr Hein\
of these features but no recall of incest at the time of interview all reported non-sexual physical abuse. In a subsequent article Ellenson gave more details of the unusual disturbances in perception[2]. Commonest were shadowy figures, movements in peripheral vision, intruder sounds, persecutory voices, directive voices and inner helper voices. Much less frequent were tactile, kinaesthetic, somatic and olfactory hallucinations. These disturbances do not fit any single syndrome. Post traumatic stress disorder provides the best fit. Psychotic depression could be considered in some cases. In an older era these patients would have likely been diagnosed as suffering from some type of hysteria. They are unlikely to have a schizophrenic illness. Since alerted by Ellenson’s articles, we have broadly confirmed these findings in more than ten patients. We must have sometimes missed the significance of childhood sexual abuse in the past. We wish to draw this possible association to the attention of Australian clinicians so that it can be tested by a wider body of
Downloaded from anp.sagepub.com at Virginia Tech on March 14, 2015
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experience. If the link is confirmed it will be valuable information for the many survivors of serious childhood sexual abuse.
casereports Three case reports will illustrate long persisting hallucinations following childhood sexual abuse. Case 1 : Maureen aged 55 presented to a community health centre in a suicidal state two months after her husband died of cancer. On most days since adolescence she had experienced voices making critical comments about her, e.g. “slut”, “whore”, “never make it”. The voices, two male and one female, were not recognised from her life experiences. One of the male voices gave positive messages. She called the most persistent critical voice “Harry”. For many years she had understood that “the voices were not real” and “they are inside my head”. She could gain short term control of the voices with talking reassuringly to herself, putting on loud music or telephoning a friend. Her father had been critical and physically abusive when she was a child; “he did all sorts of things”. When child sexual abuse was queried she veered off the topic but later acknowledged repeated frequent sexual abuse from age eight to late adolescence. Her recall was incomplete. As a young child she was forced to watch her parents having intercourse. Vaginal intercourse with her father occurred frequently, about monthly, from age eight. Around age eleven she was raped several times by a cousin seven years older. At fifteen her father encouraged her younger brothers to have intercourse with her. At sixteen she had an abortion of a pregnancy resulting from one of these incestuous relationships and the sexual abuse largely ceased. On her first unchaperoned date at nineteen she was raped. She married at twenty one and moved out of her parents’ district. She had four children. Maureen had had five psychiatric admissions between 18 and 35 years of age. Summaries have been obtained from the hospitals. All record auditory hallucinations and all diagnose schizophrenia. There was no family history of any psychoses. Maureen was experiencing “flashbacks” (her word), vivid visual memories of being raped by her father as a girl. These had often recurred throughout her adult life but were currently intense as she was frequently visiting her father, now in his eighties, dying in a nursing home “hoping he would say he was sorry”. He only continued his derogatory criticism. She had never previously disclosed the
sexual abuse and welcomed a chance to share the story over several meetings with a female counsellor. Subsequently she shared the experiences with her younger sister. Her mother had sent this sister away to boarding school at age eight and she was probably not a victim. Case 2: Amanda, aged 22, married with one child, presented stating her husband had sent her saying she was crazy and needed fixing. She was acutely anxious as for many years she had believed herself to be mad and feared she would be committed to a mental hospital. O n two previous occasions she had seen psychiatrists but had been unable to talk of the hallucinatory experiences that were worrying her. For many years she had experienced a harsh male voice inside her head, most often when she tried to sleep. This voice accused her of doing “dirty sexual things” and of being wicked and worthless. At night she was often very anxious and at times when by herself she would feel someone was watching her. She was afraid to undress at night and slept in her clothes. She mentioned that her older sister always slept wrapped in a rug even on the hottest of nights. In later sessions she revealed that she had felt worse since the birth of her daughter. She was afraid of being alone with the baby for fear she would sexually assault the child. She had difficulty changing the child’s nappy for fear of hurting the child. She thought people were watching her as they believed she was a sexual pervert, who would attack the baby. At this point she was asked when she had been sexually assaulted. She became acutely distressed, cried and finally said that she had been sexually assaulted by her father for a number of years since she was very young. Her sister had also been sexually assaulted. As a teenager she had been raped on two occasions and had been left feeling guilty that she had somehow allowed it to happen. She had never previously discussed her sexual experiences. Sharing was very difficult and she continually blamed herself. Her mother had a history of manic depressive illness and had often been in hospital. Her father was an alcoholic, who was at times physically violent. With counselling the hallucinatory experiences have ceased and she no longer regards herself as mad, though her self image is still very low. Gradually she is learning to handle and relate to her child. She still accepts a relationship with an alcoholic husband who verbally abuses her, seeing him as being good to their child and valuing the support and acceptance she gets from his family. Case 3: Nathan was 15 when referred by his school counsellor concerned about his serious depression. He
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TERRY HEINS, ALLISON GRAY, MAXINE TENNANT
had made a suicide attempt at a school camp one month previously. He was an excellent student and very articulate. He was markedly depressed and was seen for individual meetings. After several weeks trust was sufficient for him to speak about “the fish people”. These mermaid-like creatures would appear when he was alone, seeming to be opposite or beside him and on one occasion as if walking along the street with him. They were not clearly male or female. They recurringly told him that he was “sleazy”, “no good” and “useless” and “should kill himself ’. The deeper his depressed state the more frequently he experienced these hallucinations. He had been sexually abused by an uncle at several family gatherings between seven and eight years of age. He had suffered rectal bleeding on most of these occasions. This was first revealed to his family when he was interviewed by police after he had been raped by a man at age fourteen. His depression worsened and several months later he was admitted to a psychiatric unit. An initial diagnosis of schizophrenia was made by the inpatient psychiatrist and he was given anti-psychotic drugs with no benefit. However there were no features of schizophrenia apart from the hallucinations. The diagnosis was revised to depression and he was discharged on anti-depressant medication. His mood slowly improved over several weeks. As his mood lifted he was less troubled by his hallucinations. His end of year school grades were very poor. One year later he has regained academic success, but has had recurring spells of moderate depression. The hallucinations appeared to resolve as he shared the experiences of sexual abuse with a female fellow student and with a male teacher. He made more limited disclosures to his school counsellor. For a time he wrote of the abuse experiences in a journal but stopped when this was discovered by his mother. Her reaction was extreme and rejecting. More recently he has been writing poetry that alludes to the abuse.
Discussion Typically there is a strong tendency to avoid the pain andembarrassment of discussing the past abuse. When the abuse is recalled, victims rarely connect their present d e p r e s s i o n , perceptual disturbances, headaches, anger outbursts or other symptoms with the past abuse. Instead a common fear is that they are in fact going crazy. When the abuse is disclosed, it is
563
unusual to reveal perceptual disturbances[2]. The clinician needs to gently and methodically ask about these things. Useful questions include: Do you have nightmares or night terrors? What happens in your bad dreams? Do the same dreams recur? Are the dreams consistently completed or are they left unfinished? Do you ever smell things that trigger memories or feelings? Do you ever see or notice odd things? At home? When alone? When the bedroom door is closed? Do you ever hear things, particularly when alone, such as a child in distress, footsteps’? Do you ever have odd bodily sensations or feelings such as someone touching you? Transition points in psychosexual development are risk periods for abused people when symptoms and the issues are likely to resurface: puberty, dating, forming a more stable relationship, marriage, the birth of a child, a child or grandchild reaching the age at which abuse occurred or illness or death of the abuser. Hallucinations have been variously subdivided. The commonest subdivision is on perceived source of origin. True hallucinations are vivid and whole false perceptions, that are perceived as out there in the world, while pseudo-hallucinations are pathological images experienced as emanating from the mind, which are not under voluntary control[3,41. Most of these hallucinatory experiences experienced by these patients are correctly described as pseudo-hallucinations. A second subdivision is on elaborateness. Elementary hallucinations are vague, fleeting and illdefined. The vast majority of hallucinations reported by Ellenson were elementary[2]. Complex hallucinations are prolonged, detailed and vivid. Ellenson found elaborate recurring hallucinations were associated with secondary drug abuse and particularly with prolonged or vicious sexual abuse that began in early childhood.
Diagnosis The presence of hallucinations in these cases causes diagnostic confusion. Most doctors have learnt to link hallucinations with psychotic conditions, functional and organic. However hallucinations do occur in nonpsychotic conditions; in manifestations of ‘hysterical’ illness and if a traumatic experience in childhood fractures basic trust. Under current psychiatric classification all of these cases would be best initially diagnosed as Posttraumatic Stress Disorder (DSM-III-R1[5]. They meet
Downloaded from anp.sagepub.com at Virginia Tech on March 14, 2015
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the criteria of; A. The person has experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone, e.g., serious threat to one’s life or physical integrity ... B. The traumatic event is persistently re-experienced in at least one of the following ways: ... ( 3 ) sudden acting o r feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative [flashback] episodes, ... C. Persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness (not present before the trauma) ... D. Persistent symptoms of increased arousal (not present before the trauma) ... In all cases depression was prominent and in each the depression may have at times reached a psychotic degree. However psychotic depression does not seem a sufficient explanation. The hallucinatory experiences, while present at times of marked depression, also recurred without current major mood disturbance. Earlier psychiatric classifications had categories for conditions lying in the borderland between psychotic and non- psychotic conditions, which might have been applied to such patients. Psychogenic psychosis is a diagnosis long used by European psychiatrists(61. Hysterical psychosis was advocated by Hollander and H irsc h[ 71. Although hysteria has long lost favour as a diagnostic model it is interesting to recall how late nineteenth century writing on hysteria emphasised hallucinations. The hallucinatory phase (attitudes passinnelles) was the third of four phases in Charcot’s theory of hysteria[8]. The observations of Freud and Breuer tended to confirm this phase of Charcot: “Where this is present in a well marked form, it exhibits the hallucinatory reproduction of a memory which was important in bringing on the onset of the hysteria - the memory either of a single major trauma or a series of interconnected part-traumas (such as underlie common hysteria)”. 191
Evidence for a link with childhood sexual abuse A link between persisting hallucinations and childhood sexual abuse remains an inference from accumulated clinical cases. No comprehensive studies following up sexually abused children or even focussed surveys of adult patients with hallucinations have been done.
Freud is currently criticised for misnaming his patients’ accounts of childhood sexual abuse as “infantile sexual experiences”[ lo]. However in his early work he certainly recognised this link with persisting hallucinations[ 1 11. Frau P, a thirty two year old woman with “chronic paranoia”, had visual hallucinations of naked females and male genitals for several months. She heard voices that she did not recognise, commenting on her actions with threats and reproaches. She had no formed persecutory delusions. Psychoanalysis was broken off when she developed “severe hallucinations which had all the signs of dementia praecox” requiring care in an institution. However she recovered, had another child and showed no signs of psychosis over fifteen years, according to a note added in 1922 to a later edition. Freud linked her hallucinations to “the brother and sister had for years been in the habit of showing themselves to one another naked before going to bed ...I then succeeded in getting her to reproduce the various scenes in which her sexual relationship with her brother (which had certainly lasted at least from her sixth to her tenth year) had culminated ...these hallucinations were nothing else than parts of the content of repressed childhood experiences”. The final conclusion reached by Freud was that the subject’s claims of sexual abuse could have been a product of their fantasy. We have carefully considered whether such an explanation might apply to the cases we have seen. However we are convinced that the abuse did occur, substantially as recounted by these people. There is some corroboration by others, as when Maureen’s younger sister was sent to boarding school at eight and Nathan’s parents knew of rectal bleeding. That these hallucinations largely resolved with sharing and clarification seems further evidence that the sexual abuse in childhood really occurred. How specific is any link between childhood sexual abuse and these persisting hallucinations? The evidence is not clear. Ellenson has argued that these hallucinations are “unique to, and shared by, adult female incest survivors regardless of other clinical or demographic differences”[2]. However childhood sexual abuse is common[ 121 and persisting hallucinations are not rare. A broad association has been documented between childhood sexual abuse and adult psychiatric disorder in general. Sexual abuse in childhood is reported by 55%[ 13) and 46%[ 141 of adult female psychiatric inpatients. Case reports have
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TERRY HEINS, ALLISON GRAY, MAXINE TENNANT
described schizophreniform psychoses in adolescent mentally retarded girls following sexual assault[ 151. Case reports suggest childhood sexual abuse may precipitate multiple personality disorder[ 161. At the present time, when the extent and effects of childhood sexual abuse are just beginning to be adequately discussed there is some risk of seeing spurious links. However the numbers of case reports seem sufficient to draw this possible association to the attention of Australian clinicians. If the link between childhood sexual abuse and persisting hallucinations is anywhere near as specific as Ellenson has claimed, then a retrospective survey of current patients with persisting hallucinations should be a valuable next step, despite its relative methodological weakness. Any attempt to clarify this possible association further will have to dissect the broad category of childhood sexual abuse. It is probable that inappropriate or premature sexual experience of itself is not a sufficient causal factor of subsequent disorder. Most psychiatrists would know of cases of apparently benign transient sexual relationships among siblings. Anthropological studies describe cultures where sexual experimentation is not necessarily pernicious[lO]. Other causal factors are likely to be the breach of trust or the violence or seduction or confusion surrounding the experience, the continuing shame and guilt and the subsequent loss of the years of support in adolescence that would normally have come from the perpetrator. These questions will be difficult to answer in studies of groups but they are crucial in individual cases to plan sensitive treatment.
Ongoing help Our own clinical experience has convinced us of the high return from specific enquiry for childhood sexual abuse. The relief people experience, when their experiences can be shared in a supportive relationship resembles the relief that often follows enquiries about suicidal intent or sexual orientation. Starting to deal with the past abuse can be a very powerful and frightening time for the victim and family. The dissociation has protected himher from distressing memories, that are untenable within their system of values, and from the rage and guilt. Victims may fear expression of anger will lead to loss of control. Others seem influenced by an unacknowledged childhood worry that they will be punished for expressing their feelings. The family may not tolerate expression of
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anger particularly if the abuse is current or recent. Strengthening the bond between non-offending parent or parents and the child is crucial. Acknowledgement of what has happened and support assists resolution of anger, grief and depression. Sharing and clarifying the traumatic events over several meetings appears to have assisted all of the cases reported. Hallucinations have become less preoccupying and much less frequent.
Ellenson GE. Detecting a history of incest: a predictive syndrome. Social Casework: The Journal of Contemporary Social Work 1985; 66:525-532. Ellenson GE. Disturbances of perception in adult female incest survivors. Social Casework: The Journal of Contemporary Social Work 1986; 67: 149- 160. Mullen PE. The mental state and states of mind. In: Hill P, Murray R, Thorley A, eds. Essentials of Postgraduate Psychiatry. 2nd ed. London: Grune and Stratton, 1986: 3-36. Hare EH. A short note on pseudo-hallucinations. British Journal of Psychiatry 1973; 122:469-476. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Third Edition, Revised. Washington, DC, American Psychiatric Association, 1987, pp 247-25 I . Stromgren E. Psychogenic psychoses. In: Hirsch SR, Shepherd M. eds. Themes and Variations in European Psychiatry. Bristol: Wright, 1974. Hollander MH, Hirsch SJ. Hysterical psychosis. American Journal of Psychiatry 1964; 120:1066-74. Charcot J-M. Isolation in the Treatment of Hysteria In: Clinical Lectures on Diseases of the Nervous System, trans. Savill T, London: New Sydenham Society, 1889,cited In: Veith 1. Hysteria: The History of a Disease. Chicago: University of Chicago Press, 1965, p 212. 9. Breue; J, Freud S. The Psychical Mechanism of Hysterical Phenomena( 1893). In: Jones E. ed. Collected Papers of Sigmund Freud. Vol I, 24-41, London: Hogarth, 1950. 10. Ward E. Freud and the legacy of mind binding. pp 100- 117, In Father-Daughter Rape. London: The Women’s Press, 1984. 1 1. Freud S. (111) A case of chronic paranoia In: Further remarks on the neuro-psychoses of defence 1896 translated In: Jones E. ed. Collected Papers of Sigmund Freud, Vol 1. London: Hogarth, 1950, pp 174-183. 12. Kosky R. Incest: What do we really know about it? Australian and New Zealand Journal of Psychiatry 1987; 21:430-440. 13. Bryer BB, Nelson BA, Miller JB, Krol PA. Childhood sexual and physical abuse as factors in adult psychiatric illness. American Journal of Psychiatry 1987: 144: 1426- 1430. 14. Beck JC, van der Kolk B. Reports of childhood incest and current behavior of chronically hospitalized psychotic women. American Journal of Psychiatry 1987; 144: 1474-1476. 15. Varley CK. Schizophrenifom psychoses in mentally retarded adolescent girls following sexual assault. American Journal of Psychiatry 1984; 141:593-595. 16. Ament A. Rape and multiple personality disorder. American Journal ofpsychiatry 1987; 144541.
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