Neuroethics in the News Recap: Psychosis, Unshared Reality, or Clairaudiance?

By Nathan Ahlgrim

Even computer programs, like DeepDream, hallucinate.
Courtesy of Wikimedia Commons.

Experiencing hallucinations is one of the most sure-fire ways to be labeled with one of the most derogatory of words: “crazy.” Hearing voices that no one else can hear is a popular laugh line (look no further than Phoebe in Friends), but it can be a serious and distressing symptom of schizophrenia and other incapacitating disorders. Anderson Cooper demonstrated the seriousness of the issue, finding the most mundane of tasks nearly impossible as he lived a day immersed in simulated hallucinations. Psychotic symptoms are less frequently the butt of jokes with increasing visibility and sensitivity, but people with schizophrenia and others who hear voices are still victims of stigma. Of course, people with schizophrenia deserve to be treated like patients in the mental healthcare system to ease their suffering and manage their symptoms, but there is a population who are at peace with the voices only they can hear. At last month’s Neuroethics and Neuroscience in the News meeting, Stephanie Hare and Dr. Jessica Turner of Georgia State University painted the contrast between people with schizophrenia and people that scientists call “healthy voice hearers.” In doing so, they discussed how hearing voices should not necessarily be considered pathological, reframing what healthy and normal behavior should include.

Their discussion centered around the work out of Dr. Philip Corlett’s lab [1], which compared how people with schizophrenia and self-described psychics experience auditory hallucinations. An article in The Atlantic later followed, profiling one of the self-described psychic mediums and her relationship with the voices only she hears. The problem with labels comes to the fore in the very premise of the study: the psychics are labeled non-psychotic even while perceiving sounds in the absence of a noise. Mental health practitioners then must decide whether to pathologize the experience – to label it as a symptom of a disorder. Refraining from pathologizing their experience makes sense with the current definition of a “disorder,” which contains the criterion of causing distress. Because psychics are not bothered by the voices they hear, their hearing voices is not considered to be a symptom of a disorder or psychosis. However, given our society’s negative view on hallucinations and psychosis, how many people are inappropriately pathologized for similar
experiences?

Image courtesy of Pixabay.

David Rosenhan presented a pessimistic critique of how Western medicine deals with hallucinations in the 1970’s with his report, On Being Sane in Insane Places [2]. He and his colleagues presented themselves to a psychiatric ward, reporting auditory hallucinations without any other symptoms. Once committed, they behaved as they normally would and no longer reported any hallucinatory events. Even so, the healthcare professionals did not accuse or suspect them of malingering, and never granted them a clean bill of health. As a result, Rosenham and others argued that mental health professionals focus on symptoms to the exclusion of a holistic picture, and that hallucinations are overly pathologized.

Rosenhan would be happy to see the recent changes in how the American medical system treats hallucinations over the intervening decades, with continuing improvements in the Diagnostic Standards Manual (DSM). Qualifying symptoms for schizophrenia are hallucinations, delusions, disorganized speech or behavior, and negative symptoms (social withdrawal, anhedonia, etc.). Beginning with DSM III in 1980, a diagnosis required “significant impairment” associated with at least one of these symptoms. With the publication of DSM V in 2013, a diagnosis now needs at least two of these qualifying symptoms presented with significant occupational or social dysfunction. Therefore, hallucinations are no longer sufficient for a diagnosis of schizophrenia in and of themselves, and healthy voice hearers are free from diagnosis.

Stephanie Hare describing how the brain acts
during auditory hallucinations

Non-voice hearers can balk at the idea that hallucinations are part of a typical or “normal” spectrum of experience. However, anywhere between 5 and 28% of the general population experience auditory hallucinations, and only 25% of those meet the criteria for psychosis [3]. Can anything be considered abnormal if one-quarter of the population experiences it? Surprisingly, the neuroscientific evidence also supports the dissociation between auditory hallucinations and neurological disorders. Brain activity does not differ between healthy voice hearers and those with a psychiatric diagnosis when experiencing auditory hallucinations [4]. The brains of the people we label sick and healthy seem to produce auditory hallucinations in the same way. How, then, should auditory hallucinations and healthy voice hearers be treated by psychiatrists and society writ large?

The concept of non-distressing hallucinations is foreign to those whose only exposure to the phenomenon is in portrayals of schizophrenia. And yet, most healthy voice hearers classify their voices as positive, controllable, and not bothersome [1]. The resulting argument is that if hallucinations do not make the person want to seek help for their condition, we should let them be. But treatment-seeking is not always a prerequisite for a mental disorder; some disorders do not feel out of place to the individual at all. People with personality disorders often fit that category. Although Borderline Personality Disorder causes significant distress and treatment seeking, people with other personality disorders do not perceive their behavior as abnormal and are not distressed by their own behavior, as with Narcissistic Personality Disorder [5]. Overall, people with personality disorders are very likely to push against the need to treat the underlying condition [6]. Diagnoses occur because their disorder causes deleterious effects on the person’s social and professional life, not treatment seeking. But psychics can experience similar ostracization. As the medium interviewed for The Atlantic article states “You just can’t go into a room and say ‘Hey, I’m a psychic medium’ and people are gonna accept you.” Hallucinations can interfere with a person’s life whether they are attributed to schizophrenia or psychic sensitivity, with prejudices stemming from either fear or disdain. How mental health professionals define “significant distress” to accurately account for both experiences will inform how the perception of illness, and the stigma surrounding it, evolves.

Applying Lessons Learned

People with chromesthesia associate sounds with color.
Image courtesy of Wikipedia. 

Healthy voice hearers are beginning to speak out and seek acceptance. Their mission to erode the stigma surrounding auditory hallucinations does not need to start from scratch. Synesthesia, the perceptual experience of blending two or more senses, is outside the realm of typical experience, and yet synesthetes are viewed with wonder, not fear or pity. As with so many other topics, our collective internet search behavior gives away our prejudices: the top Google result for “synesthesia in the media” is the BBC article “How synaesthesia inspires artists.” In contrast, “schizophrenia in the media” returns an academic article finding the majority of schizophrenic characters in movies released between 1990 and 2010 “engaged in dangerous or violent behaviors”. Synesthesia has uniquely captured a positive public image. More directly, a specific type of hallucination has already been accepted as normal and healthy. In the grey zone between wakefulness and sleep, hypnagogic hallucinations trigger extra-sensory experiences like sudden noises or vivid visual scenes. In contrast to wakeful hallucinations, these are accepted as a non-pathological occurrence in many people’s lives.

To get to a point of similar acceptance, healthy voice hearers would benefit from a spectrum approach. Binary health/illness evaluations are now being replaced with dimensionality assessments. Auditory hallucinations may belong on one end of a spectrum of perceptual vividness, inside the range of normal experience for many people. All these strategies have one common theme: deliberate language. Calling a person ‘schizophrenic,’ ‘crazy,’ and even ‘hallucinating’ instantly pathologizes and strips the person of identity. Replacing that vocabulary with inclusive language like ‘person with schizophrenia,’ ‘psychosis,’ and even ‘nonconsensual reality’ give agency and acknowledge divergent experiences. Such deliberation over language is often accused of being too politically correct; but this is the first step in fostering a safe environment for people within the entire range of sensory experiences. Only in a safe environment can voice hearers seek help if they need it, or be transparent about their experiences if not.

 

References

[1] Powers AR, 3rd, Kelley MS, Corlett PR. (2017). Schizophr Bull 43: 84-98.

[2] Rosenhan DL. (1973). Science 179: 250-8.

[3] de Leede-Smith S, Barkus E. (2013). Frontiers in Human Neuroscience 7:

[4] Diederen KMJ, Daalman K, de Weijer AD, Neggers SFW, van Gastel W, Blom JD, Kahn RS, Sommer IEC. (2012). Schizophrenia Bulletin 38: 1074-82.

[5] Caligor E, Levy KN, Yeomans FE. (2015). The American journal of psychiatry 172: 415-22.

[6] Tyrer P, Mitchard S, Methuen C, Ranger M. (2003). Journal of personality disorders 17: 263-8.

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Ahlgrim, N. (2017). Neuroethics in the News Recap: Psychosis, Unshared Reality, or Clairaudiance?. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2017/12/neuroethics-in-news-recap-psychosis.html