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Although hallucinations may affect all the senses (sight, hearing, touch,
smell, and taste), the most frequent, and those most commonly studied, are
auditory. We know that there is a yet unsolved problem of whether envi-
ronmental or biological components predominate in the generation of
psychosis. Our own approach is to consider psychosis as a biopsychological
transformative experience, a kind of illness in which the mind can be able
to bring about transformations in its biological substrate, the brain.
It must be stated at the outset that the relationship between psychoanalysis
and the neurosciences is highly complex, and that, for epistemological and
methodological reasons, the data accruing from the two disciplines cannot be
used other than in their specific, respective, and parallel fields of inquiry. In
particular, the neurosciences can identify the causes in the strict sense of the
word of behaviour, but can tell us little about the motivations of individuals
or the meaning of personal experiences (Talvitie and Ihanus, 2011).
Judgement of reality
An important aspect of the study of hallucinations is the judgement of reality.
How does a patient confer the character of reality on stimuli which, beyond
any reasonable doubt, originate in his own mind? It is typical of the hallucina-
tory state that the patient becomes unable to distinguish between internal and
external reality and loses the faculty of reality judgement. In hallucination, a
sensory stimulus from within is projected to the outside and assumes the char-
acter of reality although it does not correspond to any external object.
How can the mind be deceived by the hallucinatory phenomenon, and
what are the conditions that facilitate an accurate judgement of reality?
Some useful indications on this complex matter are given by Mark Blechner
(2005), who wonders how we can say whether something real has happened
or whether we have only imagined or dreamt it. This author quotes Kosslyn
(1994), who considers that, in the waking state, a subsystem that polarizes
attention on the stimulus to be perceived is activated. It is unclear whether
this is the same subsystem that causes us also to believe in the reality of
dreams and figments of the imagination. The judgement of reality is appar-
ently mediated by different subsystems in dreams and imagination: in
dreams recognized by the dreamer as such, the two subsystems are both
present and are compared.
Blechner reports the singular case of a psychoanalytic patient who dreamt
of his father, who had been dead for some time. The patient had often
imagined that his father might still be alive but, in the dream, he not only
appeared alive but was also young: on waking, the patient continued to per-
ceive the figure of his father as real. He was thoroughly convinced that the
fathers presence in the dream was authentic and real, whereas he was sure
that on other occasions when he had, while awake, thought of his father as
alive, this had been pure imagination. The patient therefore seemed to have
had a hallucination in his dream, as a result of which this perception was
experienced as real even in the waking state. Blechner believes that intense
emotions in particular, mourning can give rise to an alteration in the
attribution of reality, as when a widow hallucinates her lost husband. In his
view, this demonstrates that the attribution of reality is not only based on
perception of the external world but may, on the contrary, be a quality that
the brain can assign to a particular emotional experience.
The arbitrary nature of the judgement of reality and the dependence of
its alteration on brain structures that deceive the mind is demonstrated by
an elegant neuroscientific experiment (Schacter et al., 1996). An interviewer
read out aloud a list of names of objects to a number of subjects. The same
subjects subsequently read another, written list which included some of the
names from the first list (which had therefore been heard) and others in
which the objects in the first list were given different names, which, how-
ever, had the same meaning (for instance, sweet instead of candy).
Finally, the subjects were asked whether a particular word was or was not
included in the first list. Sometimes the subjects mixed up the names in the
second list with those in the first, whereas on other occasions they remem-
bered the names from the first list perfectly well.
Using neuroimaging techniques, the investigators observed that the
hippocampus was activated whether a subject remembered correctly or
incorrectly. The difference was that, in the case of accurate recall, the audi-
tory cortex, which is responsible for auditory memory, was also activated
(the first list had been read out aloud); conversely, when the memory did not
correspond to reality although the subject was convinced that it did, the
hippocampus was activated, but not the auditory cortex. The researchers
concluded that activation of the hippocampus furnished the conviction of
the reality of the memory, regardless of whether the memory was or was
not accurate. For the same reason, it is possible to be convinced of the
reality of a false memory of abuse that never actually happened (Pally,
1997).
functioning dominated by sadism and the death drive. In her opinion, the
disposition to psychosis depended on primitive impulses and anxieties which
were normally transformed in the course of infantile development. If this
did not happen, the psychotic nuclei remained unmodified and were
destined to emerge in adulthood.
Bion (1967), on the other hand, presented a model in which psychosis did
not represent a return to primitive stages of development, but was rather
the expression of an altered capacity to think: the disorder concerned the
functions which transformed sensory perceptions into thoughts. For this
reason, the patient was unable to work through the events of his mental life
on the symbolic level.
It is beyond the scope of this paper to consider in psychoanalytic terms
the phenomenological and dynamic complexity of the psychotic state.
Among the many contributions on the subject (Abraham, 1924; Arieti,
1955; Arlow and Brenner, 1969; Aulagnier, 1985; Benedetti, 1980; Bion,
1957, 1958, 1965, 1967; Boyer, 1966; Fairbairn, 1952; Federn, 1952;
Freeman, 2001; Freud, 1894, 1911, 1915, 1923, 1924, 1932; Fromm-Reich-
mann, 1960; De Masi, 2000, 2006; Hartman, 1953; Jackson, 2001; Katan,
1954; Lacan, 195556; Lombardi, 2005; Lucas, 2009; Ogden, 1982, 1989;
Pao, 1979; Racamier, 2000; Resnik, 1972; Rey, 1994; Rosen, 1961; Rosen-
feld D, 1992; Rosenfeld H, 1965, 1969, 1978; Searles, 1965; Segal 1956,
1991; Symington, 2002; Winnicott, 1954, 1971), we choose to discuss only
those that are helpful to the psychoanalytic understanding of the nature of
the hallucinatory state.
Freud addressed the subject of hallucinations from a number of differ-
ent points of view, some of which are difficult to integrate into a
consistent whole. At first (Freud, 1894), he saw hallucination in terms
of the model of repression, regression, and the return of the repressed.
In distancing itself from an incompatible representation, the ego also
detached itself from reality, because pieces of reality were linked to the
incompatible representation. Later, in his account of the case of Schre-
ber (Freud, 1911), he attributed hallucinations to the unconscious con-
flict arising from Schrebers unconscious homosexual impulses. In his
consideration of regression (Freud, 1915), he noted that in normal cir-
cumstances reality testing made it possible to abandon hallucinatory
wish-fulfilment, whereas in the psychoses the older mode was re-
established.
Elsewhere, Freud (1924) puts forward the interesting hypothesis that
psychotic reality stems from the patients own bodily sensations, through
the confusion of proprioceptive with exteroceptive reality. He now postu-
lates that entry into psychosis takes place in two stages. Firstly, the ego
disavows (rejects) reality and detaches itself from it; then it creates a new
reality by means of a delusion or hallucination. The purpose of this new
creation is to compensate the ego for the damage sustained. The anxiety
aroused is due not to the return of the repressed (as in neurosis), but to the
re-emergence of the rejected part of reality.
hard bodily substances (cars, toy trains, etc.). In an autistic child, the
shapes have the function of mitigating the sense of non-existence, and
therefore exert a particular, bizarre fascination.
Piera Aulagnier (1985) postulates that fixation on a geographical or
sensory zone of the body prevents representational or fantasy-related
ideation. The psyche therefore hallucinates not the object but a sensory
perception. These mental experiences (pictograms) are sensory halluci-
nations, which are equivalent, in her view, to Tustins autistic shapes
and Meltzers zonal fixations the starting point for directional rever-
sal of the perceptual apparatus in autistic withdrawal.
This brief review of psychoanalytic theories on hallucinations reveals
differing hypotheses as to their genesis. Having initially been conceived as
of conflictual origin, leading to the disavowal of reality by means of massive
projection on to the outside world (Freud), they were subsequently regarded
as due to a destructive attack on the sense organs (Bion). For Lacan, hallu-
cinations result from the dissociation of the various mental functions due to
foreclosure. Tustin and Aulagnier, on the other hand, take a different view.
These two authors hold that hallucinations stem not from defensive and
destructive psychodynamic processes, but instead from a primitive, epider-
mal, and surface-related excitatory type of perception resembling that
observed in autistic disorders. They are sensory shapes that are unconnected
with thought and have the function of distancing the patient from anxiety
of the void and of non-existence.
Neuroscientific findings
Advances in brain visualization techniques (neuroimaging) have permitted
examination of brain structure and function in vivo and opened the way to
important new findings in the study of human psychopathology. The princi-
pal neuroscientific findings on hallucination are set out in a contribution by
Paul Allen et al. (2008) entitled The hallucinating brain: A review of struc-
tural and functional neuroimaging studies of hallucinations, which gathers
together the most significant studies from 1990 to 2008 and forms the basis
of the following consideration.
Hallucinatory phenomena are known to arise in, for example, cases of
brain damage. This is attributed by Braun et al. (2003) to the destruction
of the inhibitor neurons that modulate the activity of certain areas, which
are then activated in an uncontrolled manner and give rise to hallucina-
tions. In the absence of brain damage, particular areas of the brain corre-
sponding to the specific type of hallucinations have been found to be
activated. For instance, in psychotic episodes with auditory hallucinations,
McGuire et al. (1993) observed activation of Brocas area (the seat of lan-
guage), of the anterior cingulate gyrus (responsible for attention processes),
and of the temporal cortex (in charge of auditory perception and mem-
ory). These areas were found to be inactive when the patient was not
hallucinating.
An interesting finding (David et al., 1996) is that the areas of the brain
involved in the hallucinatory phenomenon are occupied and become imper-
2
Even Socrates heard voices.
he managed to see them, he replied that he saw them with the eyes of the
mind.
An interesting paper on the subject by Kenneth Hugdall (2009) uses the
evidence of neuroimaging and a battery of tests to demonstrate the differ-
ence between patients who hear inner voices and recognize them as such
and those who, on the other hand, attribute them to the outside world and
are therefore hallucinating. The experimental system was extremely rigorous
and complex, but we shall concentrate on the test results rather than on
their methodology. Whereas psychotic patients with auditory hallucinations
have lost the connection between the temporal hemisphere, in which the
voices are generated, and the prefrontal cortex, the centre of the higher
cognitive functions, subjects who recognize the voices as internal have
retained it. In the latter case, the prefrontal cortex monitors sensory experi-
ence and accurately classifies it as of internal rather than external origin.
According to this research, therefore, in psychotic hallucinations there is a
loss of function of the prefrontal areas which assign meaning to our psychic
experiences and which, in a specific case, help us to distinguish between
what is subjective that is, created by ourselves and what, on the other
hand, appears real but does not correspond to material reality. For the
patient, the voices are real, whereas for an outside observer they are not
authentic.
Limits of comparison
We have so far maintained that the neuroscientific findings on hallucina-
tions are useful because they can be related to the clinically observable
transformations of mental functioning occurring in the course of the
psychotic process. This comparison is still embryonic, partly because neuro-
scientific research is at present only at an early stage. The investigation
concerns a highly complex process. After all, the problem of hallucinations
concerns not only the nature of the perceptual processes or the path
followed by stimuli and the organs which convey them, but, in particular,
the nature of consciousness that is, the capacity to distinguish the percep-
tion of self and of ones environment from a dream or indeed a delusion.
Notwithstanding the many hypotheses (Damasio, 1994, 2010; LeDoux,
2002; Panksepp, 1998; Searle, 1997), the investigation of consciousness is
still highly problematical. For example, some neuroscientists (Damasio,
2010) consider that the brain is characterized by a prodigious ability to
create maps. When the brain creates maps, it also informs itself. The infor-
mation contained in the maps can be used without the involvement of
consciousness, as in the case of motor behaviour. The brain is continuously
informed of our bodily experiences and is always in direct contact with the
body; when it creates maps, it also creates images. At a second stage,
consciousness manipulates these images for specific purposes. The maps are
constructed when the subject interacts with external objects, or when objects
are recalled from the archives of memory.
The creation of maps applies to every sensory mode which the brain is
called upon to construct. It is not easy to determine how mapping takes
place. We only know that it does not involve a mere copy, but that the
overall composition requires the active contribution of the brain. The visual,
auditory, or other images are directly available only to the owner of the
mind in which they are formed. Various research teams have shown that
certain configurations of neural activity in the human sensory cortices cor-
respond to individual classes of objects. Hence perception results from the
brains specific cartographic ability.
However, in the current state of research, no solution has yet been found
to the problem of how the brain can produce sensory maps even in the
absence of external objects or stimuli as in the case of hallucinations. For
this reason, some questions are destined to remain unanswered for the time
being.
If the capacity for imagination that is, the faculty of creating hypothe-
ses in fantasy makes use of maps or images, how does the element that
distinguishes the false from the real come to be lost? In other words, if the
brain is able to construct as-if maps (Damasio, 2010) to predict the effects
of a given action instead of performing it, how does it happen that the sim-
ulation does not remain simulation? Is it possible for extreme emotional
states to construct maps even in the absence of external stimuli? Or can the
brain, in the case of hallucinations, forge a direct relationship with the
body, from which it receives erroneous information, instead of remaining
receptive towards the environment as in the normal situation?
Sensation
Partly owing to the contributions of Infant Research and certain neurosci-
entific findings, sensation has increasingly come to be regarded as an impor-
tant element of psychic development. Edelman and Tononi (2001) point out
that the stimuli to which a child is exposed from birth trigger and reinforce
specific schemata of neuronal activity. It is sensory stimuli that regulate the
anatomical and cellular organization of the developing nervous system
(Shore, 1994). A large number of experimental observations show that,
where a child has received insufficient sensory stimulation or lacked emo-
tional attunement during the critical period for the formation of attachment
bonds, this results in behaviour that will remain abnormal or maladaptive
throughout life.
If bodily sensory needs are appropriately satisfied, sensory gratifications
therefore come to be included in an emotional context. Physical tenderness
or kisses become exchanges with a relational quality. For this reason, sen-
sory experience differs in meaning according to the meeting of emotional
state (topdown) and sensory stimulus (bottomup). If the emotional/affec-
tive state predominates, the sensory stimulus is recorded in a relational con-
text and pleasure assumes the character of an emotional exchange.
But what happens in the case of pathology? In the absence of an
adequate emotional contribution from the caregiver, the child uses his own
body for the purposes of arousal. Sensation is then in the foreground, but
without the relational character that develops only within a situation of
good affective care. To combat a threatening sense of dissolution, a
Sensory children
Trinca (2001) postulates that, in psychotic processes, the patient is unable
to think because his mind is saturated with sensory elements that favour the
development of delusions and hallucinations. These archaic, concrete sen-
sory elements blot out the internal world, pervade and dominate the mental
processes, and block the capacity to dream as if they were impregnating
the mind with sense impressions. For this reason, a psychotic patient is
unable to develop the symbolic functions that is, the functions needed to
understand human relations on the intrapsychic level.
These observations are consistent with those of other authors (Bergman
and Escalona, 1949) who have described small children endowed with an
exceptional degree of sensory development, whether visual, auditory, tactile,
or olfactory. These children may be disturbed by sensations that are toler-
ated perfectly well by others of the same age. In all the five cases described,
the children, observed from the age of a few months up to 7 years, incline
more to sensory enjoyment than to human relations, love muffled noises,
and have a powerful sense of smell with a pronounced preference for certain
odours. One of the little girls described in this contribution hates toys, but
when playing with a piece of velvet can enter into a trance state. Some of
these children have vomiting problems from birth, in some cases so severe
as to result in surgery for presumed pyloric stenosis: these children are remi-
niscent of those suffering from merecysm described by Gaddini and Gaddini
(1959), who closed themselves off in their pleasure while ruminating their
food. Such children avoid eye contact with others and abandon themselves
to seemingly ecstatic stupefaction; they sometimes speak at a particularly
early age and then cease to do so.
Psychotic hallucinations
In the psychotic patient fantasy no longer possesses the imaginative quality
of as if and assumes the character of concrete thought. As the above clini-
cal examples show, although the mode of entry into the psychotic world dif-
fers from patient to patient, hallucinations bear witness to the extreme
development of a psychic withdrawal in which a preformed internal reality
is externalized with all the accompanying contents of anxiety or violence.3
Being endowed with a sensory and concrete quality, hallucinations easily
deceive the patient, owing to their resemblance to the perceptions that
describe the world about us in normal circumstances. Visual hallucinations
could be said to arise from seeing with the eyes of thought, and their audi-
tory counterparts from hearing with the ears of thought.
Hallucinations in the psychotic state are congruent with delusion, of
which they seem to represent a development. When they appear, the psychotic
process moves on from the ideational (delusional) level to a more thor-
oughly sensory plane. In these patients, the hallucinatory symptom arises
from sensory perceptions that are so clear and incontrovertible as to
prevent recourse to the normal experiences necessary for reality testing.
They in fact constitute a mental state in which hallucinations are as it were
prepared by the delusional psychotic part that dominates, seduces, and
intimidates the patient.
An author/patient called Perceval (Bateson, 1961), who wrote the history
of his illness after his discharge from hospital, graphically illustrates the
process of progressive emergence from the hallucinatory world. Towards
the end of his confinement in the asylum, when gradually coming out of his
psychosis, Perceval was able to distance himself from the voices that had
tormented and held sway over him for years:
Here it was that I discovered one day, when I thought I was attending to a voice
that was speaking to me, that, my mind being suddenly directed to outward objects,
the sound remained but the voice was gone [. . .]. I found, moreover, if I threw
myself back into the same state of absence of mind, that the voice returned [. . .];
and, prosecuting my examinations still further, I found that the breathing of my
nostrils also, particularly when I was agitated, had been and was clothed with
words and sentences [. . .]; from which I concluded that they were really produced
in the head or brain, though they appeared high in the air, or perhaps in the cor-
nice of the ceiling of the room [. . .]
(Bateson, 1961, p. 294f.)
3
In most cases hallucinations in the psychotic process are secondary to delusion and therefore of later
onset, as is borne out by the fact that in drug treatment they disappear first (initially their intensity only
is diminished). The delusional ideation, for its part, is more stubborn and persists for longer (Schneider
et al., 2011).
prevails, the other disappears. For the creation of the hallucinatory state, a
mental condition of passive acquiescence appears to be necessary. While
recovering from his illness, Perceval is seemingly doing his best to recognize
the existing of the outside world and thereby to escape from the power of
the delusional fantasy that has kept him prisoner and rendered him passive.
The patients we discuss below are all characterized by having a psychotic
part prevailing over the rest of a healthy personality. This is the situation in
which delusions and hallucinations clinically develop. The following cases
are merely psychopathological examples of various forms of hallucinatory
activity: we are not aiming to illustrate the clinical work undertaken in each
individual case, with the analysis of any eventual transference or counter-
transference development.
Berta
Berta is 7 years old when she first comes for a consultation.4 The parents
are worried because she is often agitated, irritable, and subject to fits of cry-
ing and rage. She puts objects into her mouth, constantly repeats the same
sentences, and has difficulty in socializing with her schoolmates of the same
age.
In the first consultation, the therapist is surprised by how easily Berta
separates from the mother figure. What worries him is the lack of eye con-
tact, as if she were somewhere else. On entering the room, the little girl
places some dolls on the desk, heads for the soft play area in the corner
(which takes the form of a mattress), and begins to show how elastic she
is. She explains that she was very frightened about coming along to the ana-
lyst: I thought it would be like coming to Dr . . ., who operated on my
throat.5
Berta has a rich fantasy life, is highly imaginative, and has a very
advanced vocabulary for her age. She is later to talk for a long time about
secrets that cannot be divulged. Sessions will begin as follows: I have a
secret, but I cant tell it to you. As she subsequently explains, the secrets
also concern the wish to sample her bodily products. She plays a lot with
her saliva and with plasticine, which she often even eats. In one game, she
hides a tiny little goat in the plasticine, and then laboriously causes it to
re-emerge.
Eventually the game with the little goat encased in plasticine proves no
longer capable of protecting her from the worlds ferocity, as the animal is
impaled on the horn of a rhinoceros. Berta sometimes uses a doll represent-
ing a male figure as if it were a ball: she shapes it, throws it, and deliber-
ately avoids catching it in flight. Ive killed it . . . hundreds of times . . .,
she pronounces in one session; and, in another: I am a serial killer. She
now seems to be identified with a terrifying character, which apparently
confirms her perception of being very bad and therefore a possible victim of
4
This patients material was supplied by Dr Agostino Napoletano, who has kindly allowed us to use it.
Berta was treated with a two-sessions-a-week child psychotherapy.
5
The girl has a prominent scar on her neck from surgery on the hyoid when she was very small. Such sit-
uations tend to return in the hallucinations of disfigured little girls.
Rino
6
Rino is 20 years of age and comes for a consultation in November after
spending four months in hospital on account of a psychotic breakdown:
during July he succumbed to persecutory delusions, visual and auditory hal-
lucinations (of a persecutory and imperative nature), severe behavioural dis-
turbances, and fits of destruction. The delusions at first involved mainly
persecution by members of a gang of young drug addicts (of which Rino
had been a member for some years), who subjected him to terrible threats
and physical violence; the delusions then became more complex, with the
entry on the scene of Mafia gangs and Islamic terrorists (eventually he came
into the sights of Osama bin Laden). The patient attributed the actual onset
of the delusion to a specific episode: a challenge by one of the boys in the
gang who came to his house with a girl (whom Rino also fancied) and
provoked him with his stare. Eventually Rino had given him one of his
fluid-laden looks that was so powerful that the other had been utterly
floored and forced to flee. The persecution had begun shortly afterwards
and Rino had tried to escape to Rome, where he had an uncle and aunt;
they then managed to bring him back to Milan and have him admitted to
hospital. The auditory hallucinations had at first been characterized by
good and protective voices (priests from his infant school, or teachers), but
the voices then became bad and satanic (the gang, Mafia people, and crimi-
nals). The voices had then become particularly threatening, with the inter-
vention of Islamic terrorism, and had almost persuaded him to commit
suicide by jumping from a balcony: If you jump, you will at least not be
recruited by the terrorists as a suicide bomber. In the first few days of his
confinement in hospital, the patient had also suffered from tactile hallucina-
tions, which the patient experienced as terrible violence inflicted on his body
by the persecutors. The gang that was persecuting him began to torture him
physically, driving nails into his skin and striking him with hammer blows.
6
Rino was treated with a two-sessions-a-week psychotherapy, in vis-
a-vis setting.
Alvise
7
Alvise suffered a serious psychotic episode at the age of 25, when he was
admitted to hospital for two months and underwent drug treatment. The
breakdown had culminated in a suicide attempt: while on holiday, he had
jumped off a flyover while under the delusion of harbouring a devilish
power within that made him totally destructive. Alvise had felt that he
could enter telepathically into other peoples minds, and this had triggered
his attempt on his own life.
In the first two years of his analysis, Alvise often felt hated and despised
by people so that he avoided contact with neighbours, strangers, and later
also friends. In a second phase, these perceptions became organized as audi-
tory hallucinations. Alvise had become a negative entity that lived in the
minds of others and was universally despised. The hallucinations would arise
without warning, attacking him with disparaging accusations and plunging
him into a state of terror. It was impossible to suggest to the patient that the
hallucinations stemmed from his own mind; he really could see and hear
people speaking ill of him, and hear the neighbours commenting on or allud-
ing to his insanity. On one occasion he described a hallucinatory attack
(involving the usual comment Hes mad, mad as a hatter) after a row with
his mother, who had seemed to him overbearing and intrusive. Alvise said
that if he rebelled against the voices, he would be persecuted even more;
he felt that an aggressive counter-attack on the persecutors would have
7
Alvise was followed with a classical psychoanalytic setting (four sessions a week on the couch).
brought back the confusion and the catastrophic sense of guilt. So he could
only submit with resignation to the aggression of the voices.
Alvise seemed to have introjected an annihilating object that had become a
part of himself. Working with the patient, especially in the intervals between
hallucinatory episodes, I was later able to identify a specific time, tantamount
to a period of incubation, when the destructive, guilt-inspiring voices came
into being. Whenever, outside the sessions, he happened to feel sad and
isolated from everyone, this caused hatred and violence towards the rest of
the world to grow within him. The culmination of the paroxysmic hate
coincided with the collapse of the psychic boundary (the loss of his psychic
cranium and shield), resulting in perceptual holes that were the source of
the peoples aggressive thoughts which ran him through and terrified him.
We gradually came to understand that the mental state into which he
withdrew, in which the sadomasochistic isolation of a victim was mixed
with hate, was the fertile soil for the production of the hallucinations. The
hallucinatory experience was preceded by loss of the perception of psychic
reality and of the separation between himself and others (he was acquainted
with other peoples thoughts, which subsequently became hallucinatory
attacks).
8
This may be one reason why dreams too appear to the dreamer as real events, but are perceived as
having been dreamt when the dreamer regains consciousness on waking. In the hallucinatory process,
on the other hand, the perception lacks anything to compare it with and remains stable, concrete, and
real. The father hallucination in the dream of Blechners (2005) patient is highly instructive in this
connection.
Some considerations
As we have seen, neuroscientists use the technique of neuroimaging to dem-
onstrate what happens on the neurophysiological level (that of the brain) as
the psychotic process progresses in the psyche (the mind). The psychosis over-
comes the mind because it deactivates and paralyses the faculties of discrimi-
nation and thought that are located predominantly in the prefrontal regions.
In practice, the creation of the psychotic sensory retreat contributes to the
permanent enfeeblement of the capacity for discrimination and self-criticism.
This is because the patient can succeed in remaining in the self-excitatory sen-
sory retreat only by inhibiting the operation of the brain centres essential to
emotional reception of the environment and to the judgement of reality.
The hallucination avails itself of the capacity of the psychotic part of the
personality to sensorially transcribe an imaginative thought. During the hallu-
cinatory experience, the patient does not think, he sees or feels.
From the neuroscientific point of view, sensory stimuli do not reach the
centres responsible for the cognitive functions, where they could be analysed
and distinguished, but are detained on the level of the sensory areas, where
they are used autistically. As Hugdall et al. (2009) have shown, when the
connection to the prefrontal regions remains intact, the voices retain their
connotation of reality; they are not projected to the outside world and are
perceived as inner voices.
The psychotic solution appears to be an attempt to transform the mental
apparatus by way of the acquired capacity to alter the organs of perception,
thus compromising the sense of reality and transforming the personal iden-
tity. In this way, the psychotic part of the personality tries to annihilate
human relations and blots out the sense of awareness of self, the body, and
the mind. Once under way, this transformation of the mind is difficult to
stop, precisely because it confuses the patient as to the pathological nature
of the process, which is mistaken for the opening up of a stimulating new
perspective of perception and awareness.
The alteration of the relations between interdependent areas of the brain
raises the problem of whether these modifications can be reversed. In one
sense, the reversibility of the psychotic transformations and the disappear-
ance of the associated symptoms are not easy to bring about without the
assistance of psychopharmaceutical drugs, which can attenuate or remove
the hallucinatory symptoms, albeit without acting on their underlying emo-
tional or psychological causes. Hallucinations or delusions also represent
inappropriate responses constructed by the patient to insoluble problems
and always leave traces that facilitate their repetition.
Conclusions
The hypothesis put forward in this contribution takes account of the possi-
ble biological foundation of psychosis and of the complex relationship
The patient feels imprisoned in the state of mind he has achieved and unable to
escape from it because he lacks the apparatus of awareness of reality which is both
the key to escape and the freedom itself to which he would escape.
Translation of summary
Halluzinationen im psychotischen Zustand. Psychoanalyse und Neurowissenschaften im Vergl-
eich. In diesem Beitrag untersucht der Autor unter Ber ucksichtigung wichtiger Erkenntnisse der Neuro-
wissenschaften wie auch der psychoanalytischen Forschung die Bedeutung der tiefreichenden
Verzerrungen, die das mit halluzinatorischen Phanomenen einhergehende psychische Funktionieren
begleiten. Neurowissenschaftliche Studien belegen, dass Halluzinationen den Realitatssinn infolge kom-
plexer Veranderungen des Verhaltnisses zwischen Top-down- und Bottom-up-Schaltkreisen des Gehirns
verzerren. Die Autoren des Beitrags postulieren halluzinatorische Phanomene als Ergebnis der langerfris-
tigen, verzerrten Anwendung seines psychischen Apparats durch den Psychotiker. Im halluzinatorischen
Zustand benutzt der psychotische Teil der Pers onlichkeit den psychischen Apparat, um autoinduzierte
Sensationen hervorzubringen und eine spezifische Art regressiver Lust zu erzeugen. Die Psyche wird
daher in diesen Fallen nicht als Organ der Erkenntnis oder als Instrument zur Vertiefung
zwischenmenschlicher Beziehungen benutzt. Der halluzinierende Psychotiker zieht die Besetzung der psy-
chischen (relationalen) Realitat zur
uck und isoliert sich in seinem pers
onlichen, k
orperlichen und senso-
rischen Raum. Die polaren Realitaten betreffen nicht allein Auen und Innen, sondern auch Psychisches
und Sensorisches. Dementsprechend k onnte man sagen, dass visuelle Halluzinationen das Ergebnis eines
Sehens mit den Augen der Psyche seien und dass akustische Halluzinationen durch das H oren mit den
Ohren der Psyche generiert werden. Das mentale Funktionieren ist bei diesen St orungen bar samtlicher
reiferer Funktionen; das bedeutet, dass der Umwelt und dem psychischen Erleben des Individuums keine
genuine Bedeutung mehr zugeschrieben werden kann. Neurowissenschaftliche Ergebnisse erleichtern es
zu verstehen, wie der psychische Apparat im psychotischen halluzinatorischen Prozess die Arbeitsweise
eines Korperorgans, in diesem Fall des Gehirns, verandern kann.
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