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Hallucinations and pathological visual perceptions in Maupassant's fantastical short stories--a neurological approach.

Maupassant excelled as a realist writer of the nineteenth century, with fantastical short stories being an outstanding example of his literary genius. We have analysed four of his fantastical stories from a neurological point of view. In "Le Horla," his masterpiece, we have found nightmares, sleep paralysis, a hemianopic pattern of loss and recovery of vision, and palinopsia. In "Qui sait" and in "La main" there is also an illusory movement of the objects in the visual field, although in a dreamlike complex pattern. In "Lui," autoscopy and hypnagogic hallucinations emerge as fantastical key elements. The writer suffered from severe migraine and neurosyphilis involving the optic nerve, which led to his death by general paralysis of the insane (GPI). Visual loss and visual hallucinations affected the author in his last years, before a delirant state confined him to a nursing home. Our original hypothesis, which stated that he could have translated his sensorial experiences coming from this source to his works, had to be revised by analyzing some of his earliest works, notably "Le Docteur Héraclius Gloss" and "La main d'écorché" (1875). We found hallucinatory symptoms, adopting the form of autoscopy and other elaborated visual misperceptions, in stories written at age 25, when Maupassant was allegedly healthy. Therefore, we hypothesize that they may be related to his hypersensitive disposition, assuming that no pathology is necessary to experience such vivid experiences. In addition, Maupassant's abuse of drugs, as illustrated in "Rêves," could have provided an additional element to outline his painstaking visual depictions. All these factors, in addition to his up-to-date neurological knowledge and attendance at Charcot's lectures at "La Salpêtrière," armed the author for repetitive and enriched hallucinatory experiences, which were transferred relentlessly into his works from the beginning of his career.

Fantasy↗

The dreamy state: hallucinations of autobiographic memory evoked by temporal lobe stimulations and seizures.

Using results from cortical stimulations, as well as the symptoms of spontaneous epileptic seizures recorded by stereoelectroencephalography we re-studied the phenomenon of the dreamy state, as described by Jackson (Jackson JH. Selected writings of John Hughlins Jackson. Vol 1. On epilepsy and epileptiform convulsions. Taylor J, editor. London: Hodder and Stoughton; 1931). A total of 15 sensations of déjà vécu, 35 visual hallucinations consisting of the image of a scene and 5 'feelings of strangeness' occurred. These were recorded during 40 stimulations in 16 subjects, and 15 seizures in 5 subjects. Forty-five per cent of dreamy states were evoked by stimulation of the amygdala, 37.5% by the hippocampus and 17.5% by the para-hippocampal gyrus. During both spontaneous and provoked dreamy state, the electrical discharge was localized within mesial temporal lobe structures, without involvement of the temporal neocortex. Early spread of the discharge to the temporal neocortex appeared to prevent the occurrence of the dreamy state. Semiological analysis showed a clinical continuity between déjà vécu and visual hallucinations, the latter often consisting of a personal memory that was 'relived' by the subject; such memories could be recent, distant or from childhood. With one exception, the particular memory evoked differed from one seizure to another, but were always drawn from the same period of the subject's life. Given the role of the amygdala and hippocampus in autobiographic memory, their pathological activation during seizures may trigger memory recall. This study of the dreamy state is in keeping with other evidence demonstrating the constant and central role of the amygdala and hippocampus (right as much as left) in the recall of recent and distant memories. It demonstrates the existence of large neural networks that produce recall of memories via activation of the hippocampus, amygdala and rhinal cortex.

Adolescent↗

Auditory hallucinations, source monitoring, and the belief that "voices" are real.

The term source monitoring refers to a variety of cognitive processes individuals use to determine whether an experience originated within the self or came from an external source. A belief that auditory hallucinations are real entities independent of the self may be considered an error in source monitoring. The Source Monitoring Framework (SMF) is the most developed and empirically validated model of how ordinary individuals judge whether an event was self-generated or occurred in the outside world. This study of 41 acute inpatients is a first attempt to apply the SMF to autobiographical reports of auditory hallucinations in a clinical setting. Consistent with the SMF, results suggest that similarities between "voices" and real speakers may offer a partial explanation of why patients believe the voices are real. While the SMF provides a useful conceptual background for examining the phenomenology of these voices, the types of source monitoring errors typically encountered in normal individuals do not fully account for this belief as it occurs in psychotic individuals.

Cognition Disorders↗

Hallucination focused integrative treatment: a randomized controlled trial.

Improvements in psychopathology, subjective burden, and coping with voices after hallucination focused integrative treatment (HIT) were studied in chronic schizophrenic patients with persistent (> 10 years), drug-refractory auditory hallucinations. In a randomized controlled trial, routine care was compared with HIT pre- and posttreatment at a 9-month interval. Independent raters used semistructured interviews to assess burden, symptoms, and coping. Within-group improvements in both burden and psychopathology were most significant in the experimental group (p < 0.05) after treatment. HIT patients showed change in applied coping strategies, but it did not reach statistical significance. Type and (change in) number of coping strategies did not seem related to outcome. The results suggest that HIT is a cost-effective practice that positively affects mental state in general, subjective burden, quality of life, and social functioning.

Adaptation, Psychological↗

Is chronicity a function of the relationship between the person and the auditory hallucination?

Thirty psychiatric inpatients each rated their relationship with their auditory hallucination using the Structural Analysis of Social Behavior questionnaires which assess partnerships in terms of interpersonal focus, love-hate, and enmeshment-differentiation. Results showed that all subjects had integrated, interpersonally coherent relationships with their voice. Qualitative differences in the nature of the relationships related meaningfully to diagnosis. Selected clinical excerpts suggested that the relationship with the hallucination may serve an adaptive function. Chronicity may be dependent on the nature of that adaptation.

Chronic Disease↗

Visual hallucinations induced by deep brain stimulation in Parkinson's disease.

We report a patient with idiopathic Parkinson's disease who underwent bilateral deep brain stimulation (DBS) of the nucleus subthalamicus (STN) and developed visual hallucinations (VH) while taking no medications only when the DBS was turned on. The hallucinations resolved when the stimulator was turned off. The phenomenology and the prompt response to clozapine suggest that DBS-induced VH mimic pharmacologically-induced VH.

Electric Stimulation Therapy↗

Visual hallucinations due to indomethacin: a case report.

Visual hallucinations may be caused by organic cerebral lesions and by drugs including indomethacin. We report here a case of indomethacin-induced visual hallucinations in which a clear description of the phenomenology shows how a complex hallucinatory experience may arise from the relatively non-specific effects of cerebral irritation.

Adult↗

Verbal auditory hallucinations: mind, self, and society.

Verbal auditory hallucinations of schizophrenic patients are usually sensed as coming from m-ltiple voices. The voices are usually not recognized by patients; they are anonymous. They are expressed mainly in the second person (as if directed to the patient by others), occasionally in the third person (as if two or more persons are overheard talking about the patient), very rarely in the first person. They are sensed as separate from the self and out of the patient's control. All of these characteristics can be said to describe how a person generalizes from his social experiences a societal evaluation of himself. In addition, the voices of schizophrenic patients are predominantly disparaging, call approbrious names, or are accusatory. Schizophrenics tend to come from and be of low socioeconomic status. The hallucinations appear to be related to the schizophrenic's sense of society's disparagement of him because of his low socioeconomic status and achievement.

Adult↗

Conversive hallucinations.

Reports of conversive hallucinations are rare in the literature. A case is presented describing the psychogenesis and phenomenology of hallucinations experienced by a female patient.

Adult↗

Auditory hallucinations and schizophrenia.

Forty-five patients with auditory hallucinations were studied. Sixty per cent proved to be excellent hypnotic subjects with multiple personalities. These latter patients received 11 different diagnoses by clinicians, predominantly those related to schizophrenia or an affective illness. Because patients with multiple personalities frequently have hallucinations, delusions, paranoid ideas and bizarre behaviors, they may be misdiagnosed as some form of schizophrenia.

Auditory Perception↗

Hallucinations vs. delusions. A developmental approach.

The developmental levels of three samples of paranoid and nonparanoid schizophrenic patients who manifested hallucinations, delusions, or both symptoms were compared. The patient sample consisted of 432 men and 207 women. Developmental level was assessed by the Zigler-Phillips Social Competence Index. Patients who manifested delusions were found to be at a higher developmental level than those who suffered hallucinations. The social competence of patients having both symptoms tended to fall between the levels of the single symptom groups. Females had higher competence scores than males, and paranoid patients had higher scores than nonparanoid patients. The results were discussed in terms of the significance of developmental level as a pervasive dimension of the individual which relates to the expression of specific symptoms and other facets of psychiatric disorder.

Adult↗

Visual hallucinations in the 19th century: research in a medical archive.

The authors have gathered and analyzed the visual hallucinations described in the mid- to late-19th century from archived medical records of the former psychiatric hospital "Osservanza" in Imola, northern Italy. Though the investigation was not intended as a statistical survey, the principal aim being to classify the hallucinations according to their outward characteristics, the authors have tried to locate the possible sources of these phenomena in folklore and religious iconography.

Archives↗

Migraine-like visual hallucinations in occipital lesions of cysticercosis.

Four Indian patients with occipital lesions of cysticercosis presented with visual hallucinations. Neuro-ophthalmic and systemic examinations were normal in all cases except for one patient who had a partial homonymous hemianopia. Electroencephalography was normal in all cases. Neuroimaging revealed ring-enhancing lesions in the occipital lobe typical of neurocysticercosis. In endemic regions like India, neurocysticercosis should be suspected in patients presenting with visual hallucinations, even when there are no other clinical findings.

Adolescent↗

The role of the prefrontal cortex in self-consciousness: the case of auditory hallucinations.

Many patients with schizophrenia report hallucinations in which they hear voices talking to them or about them. Behavioural and physiological studies show that this experience is associated with processes occurring in auditory language systems associated with both the production and the reception of speech. I propose that hallucinations are experienced because patients have difficulty in distinguishing sensations caused by their own actions from those that arise from external influences. This distinction can be made by predicting the sensations that will result from executive commands (forward modelling). If the predicted sensation matches the actual sensation then no outside influences have occurred and perception of change can be 'cancelled'. At the physiological level this mechanism depends upon interactions between the prefrontal areas where the executive commands originate and posterior brain regions concerned with the resultant sensations. Evidence from functional brain imaging confirms that interactions between prefrontal (executive) areas and auditory association areas are abnormal in schizophrenia. However, this account needs to be extended before we can understand why patients experience the voices as emanating, not just from an external source, but from agents who are trying to influence their behaviour. Recent imaging studies suggest that medial prefrontal cortex is engaged when we think about other people, but the precise nature of the interaction of this brain area with other regions remains to be established.

Consciousness↗

Geometric visual hallucinations, Euclidean symmetry and the functional architecture of striate cortex.

This paper is concerned with a striking visual experience: that of seeing geometric visual hallucinations. Hallucinatory images were classified by Klüver into four groups called form constants comprising (i) gratings, lattices, fretworks, filigrees, honeycombs and chequer-boards, (ii) cobwebs, (iii) tunnels, funnels, alleys, cones and vessels, and (iv) spirals. This paper describes a mathematical investigation of their origin based on the assumption that the patterns of connection between retina and striate cortex (henceforth referred to as V1)-the retinocortical map-and of neuronal circuits in V1, both local and lateral, determine their geometry. In the first part of the paper we show that form constants, when viewed in V1 coordinates, essentially correspond to combinations of plane waves, the wavelengths of which are integral multiples of the width of a human Hubel-Wiesel hypercolumn, ca. 1.33-2 mm. We next introduce a mathematical description of the large-scale dynamics of V1 in terms of the continuum limit of a lattice of interconnected hypercolumns, each of which itself comprises a number of interconnected iso-orientation columns. We then show that the patterns of interconnection in V1 exhibit a very interesting symmetry, i.e. they are invariant under the action of the planar Euclidean group E(2)-the group of rigid motions in the plane-rotations, reflections and translations. What is novel is that the lateral connectivity of V1 is such that a new group action is needed to represent its properties: by virtue of its anisotropy it is invariant with respect to certain shifts and twists of the plane. It is this shift-twist invariance that generates new representations of E(2). Assuming that the strength of lateral connections is weak compared with that of local connections, we next calculate the eigenvalues and eigenfunctions of the cortical dynamics, using Rayleigh-Schrödinger perturbation theory. The result is that in the absence of lateral connections, the eigenfunctions are degenerate, comprising both even and odd combinations of sinusoids in straight phi, the cortical label for orientation preference, and plane waves in r, the cortical position coordinate. 'Switching-on' the lateral interactions breaks the degeneracy and either even or else odd eigenfunctions are selected. These results can be shown to follow directly from the Euclidean symmetry we have imposed. In the second part of the paper we study the nature of various even and odd combinations of eigenfunctions or planforms, the symmetries of which are such that they remain invariant under the particular action of E(2) we have imposed. These symmetries correspond to certain subgroups of E(2), the so-called axial subgroups. Axial subgroups are important in that the equivariant branching lemma indicates that when a symmetrical dynamical system becomes unstable, new solutions emerge which have symmetries corresponding to the axial subgroups of the underlying symmetry group. This is precisely the case studied in this paper. Thus we study the various planforms that emerge when our model V1 dynamics become unstable under the presumed action of hallucinogens or flickering lights. We show that the planforms correspond to the axial subgroups of E(2), under the shift-twist action. We then compute what such planforms would look like in the visual field, given an extension of the retinocortical map to include its action on local edges and contours. What is most interesting is that, given our interpretation of the correspondence between V1 planforms and perceived patterns, the set of planforms generates representatives of all the form constants. It is also noteworthy that the planforms derived from our continuum model naturally divide V1 into what are called linear regions, in which the pattern has a near constant orientation, reminiscent of the iso-orientation patches constructed via optical imaging. The boundaries of such regions form fractures whose points of intersection correspond to the well-known 'pinwheels'. To complete the study we then investigate the stability of the planforms, using methods of nonlinear stability analysis, including Liapunov-Schmidt reduction and Poincaré-Lindstedt perturbation theory. We find a close correspondence between stable planforms and form constants. The results are sensitive to the detailed specification of the lateral connectivity and suggest an interesting possibility, that the cortical mechanisms by which geometric visual hallucinations are generated, if sited mainly in V1, are closely related to those involved in the processing of edges and contours.

Animals↗

Recurrent hallucinations following ketamine.

Recurrent hallucinations appeared in an 11-year-old boy during 5 days following ketamine anaesthesia. Previous anaesthesia with ketamine and adequate diazepam supplementation did not produce any such effect. The phenomenon of delayed recurring hallucinations is a rare but dangerous side-effect of ketamine, not unlike LSD flashbacks. The described case lends support to previous reports on the value of diazepam in the prevention of post-ketamine perceptual abnormalities.

Anesthesia, General↗

Hallucinations after a therapeutic dose of benzodiazepine hypnotics with co-administration of erythromycin.

A case of repetitive hallucinations during treatment with a therapeutic dosage of triazolam (0.25 mg/day) and nitrazepam (5 mg/day) is presented. The patient suffered from acute pneumonia and chronic renal failure. Such non-psychotic symptoms as anxiety, tremor and depressed feeling were observed initially. However, after co-administration of erythromycin (600 mg/day), visual hallucinations and abnormal bodily sensations developed repeatedly after each administration of triazolam or nitrazepam. This report suggests that benzodiazepine hypnotics even at a therapeutic dosage with co-administration of erythromycin causes serious psychotic symptoms in vulnerable patients with physical complications.

Anti-Anxiety Agents↗

Visual hallucinations after acute visual loss in a young child.

A four-year-old boy developed complex visual hallucinations consisting of moving figures, animals and other familiar objects one week after becoming totally blind. This followed a six-month period of gradually deteriorating vision and was precipitated by the debulking of a large optic nerve glioma. Although visual hallucinations are well recognised in adults with visual loss, secondary to both ophthalmological and neurological causes, they have not been reported in young children.

Blindness↗