Hallucinations

1

My own favorite definition is that given by William James in his 1890 Principles of Psychology: “An hallucination is a strictly sensational form of consciousness, as good and true a sensation as if there were a real object there. The object happens to be not there, that is all.” Many other researchers have proposed their own definitions, and Jan Dirk Blom, in his encyclopedic Dictionary of Hallucinations, includes dozens of these.

2

We cannot be certain whether other animals have hallucinations, although “hallucinatory behaviors” have been observed in laboratory animals as well as in natural settings, as Ronald K. Siegel and Murray E. Jarvik described in their review of the subject.

3

La Barre provided an extended review of anthropological perspectives on hallucination in a chapter published in 1975.

4

Draaisma’s book provides not only a vivid account of Bonnet’s life and work, but fascinating reconstructions of the lives of a dozen other major figures in neurology whose names are now remembered mostly for the syndromes named after them: Georges Gilles de la Tourette, James Parkinson, Alois Alzheimer, Joseph Capgras, and others.

5

Or so it would seem. Recently I came across a marvelous 1845 report by Truman Abell, a physician who started to lose his sight in his fifty-ninth year and had become totally blind by 1842, four years later. He described this in an article for the Boston Medical and Surgical Journal.

“In this situation,” he wrote, “I often dreamed of having my sight restored, and of seeing the most beautiful landscapes. At length these landscapes began to appear in miniature when awake: small fields, a few feet square, would appear, clothed with green grass, and other vegetables, some in bloom. These would continue two or three minutes, and then disappear.” The landscapes were followed by an immense variety of other “illusions” — Abell did not use the word “hallucinations” — provided by “an internal sight.”

Over the course of several months, his visions increased in complexity. His “silent, but impudent visitors” were sometimes intrusive, with three or four people who would sit on his bed or “come to my bed-side, stoop down over me, and look directly into my eyes.” (Often his hallucinatory people seemed to acknowledge him, although CBS hallucinations typically do not interact with their hallucinators.) One night, he reported, “I was threatened to be run over about 10 o’clock by a drove of oxen; but having my presence of mind, I sat quiet, and with much crowding they all passed without touching me.”

Sometimes he saw ranks of thousands of people, splendidly dressed, forming columns that disappeared into the distance. At one point he saw “a column at least half a mile wide” of “men on horseback riding towards the west.… They continued to pass for several hours.”

“What I have here stated,” Abell wrote at the end of his detailed account, “must appear incredible to those unacquainted with the history of illusive visions.… How far my blindness contributed to produce such a result, I am not able to say. Never before have I been able to realize the ancient comparison of the human mind to a microcosm, or universe in miniature … [yet] the whole was confined within the organ of mental vision, and occupied, perhaps, a space of less than the tenth part of an inch square.”

6

A particularly good description of hallucinations in CBS (“I See Purple Flowers Everywhere”) is provided by Lylas and Marja Mogk in their excellent book Macular Degeneration, written for patients with this condition.

7

The reverse may also occur. Robert Teunisse told me how one of his patients, seeing a man hovering outside his nineteenth-floor apartment, assumed this was another one of his hallucinations. When the man waved at him, he did not wave back. The “hallucination” turned out to be his window washer, considerably miffed at not having his friendly wave returned.

8

I have heard from at least a dozen people who, like Arthur and Marjorie, hallucinate musical notation; some of them have eye problems, some parkinsonism, some see music when they have a fever or delirium, some see it hypnopompically when they awaken. All but one are amateur musicians who often spend many hours a day studying scores. This very specialized and repetitive sort of visual study is peculiar to musicians. One may read books for hours a day, but one does not usually study print itself in such an intensive way (unless one is a type designer or proofreader, perhaps).

A page of music is far more complex visually than a page of print. With musical notation, one has not just the notes themselves but a very dense set of information contained in symbols for key signatures, clefs, turns, mordents, accents, rests, holds, trills, etc. It seems likely that intensive study and practice of this complex code somehow imprints it in the brain, and should any tendency to hallucination later develop, these “neural imprints” may predispose to hallucinations of musical notation.

And yet people with no particular training or even interest in music may also have hallucinations of musical notation, as Dominic ffytche has pointed out. In a letter to me, he wrote, “although prolonged exposure to music increases the likelihood of musical eyes, it is not a prerequisite.”

9

I was reminded, when she said this, of a case I had heard of in which as a patient ate cherries from a bowl, they were replaced by hallucinatory cherries, a seemingly endless cornucopia of cherries, until, suddenly, the bowl was totally empty. And of another case, of a man with CBS who was picking blackberries. He picked every one he could see; then, to his delight, he saw four more he had missed — but these turned out to be hallucinations.

10

Something about visual movement or “optic flow” seems to be especially provocative of visual hallucinations in people with CBS or other disorders. I met one elderly psychiatrist with macular degeneration who had experienced only a single episode of CBS hallucinations: he was being driven in a car and began to see, on the edges of the parkway, elaborate eighteenth-century gardens which reminded him of Versailles. He enjoyed the experience and found it much more interesting than the ordinary view of the roadside.

Ivy L., who also has macular degeneration, wrote:

As a passenger in cars, I began riding with my eyes closed. Now I often “see” a small, moving travel scene in front of me when my eyes are shut. I “see” open roads and sky, houses, and gardens. I do not “see” any people or vehicles. The scene constantly changes, showing unidentifiable houses in great detail sliding by when the car is in motion. These hallucinations never appear except when I am in a moving car.

(Mrs. L. also reported text hallucinations as part of her CBS, “brief periods when I would ‘see’ handwriting in huge letters across a large white wall, or the income tax figures imprinted on the drapes. These lasted several years, at intervals.”)

11

Such correlations involve sizable regions of the brain; they are at a macro level. Correlations on a micro level, at least for elementary geometric hallucinations, have been proposed by William Burke, a neuro-physiologist who has experienced such hallucinations himself, due to macular “holes” in both eyes. He has been able to estimate the visual angles subtended by specific hallucinations and to extrapolate these into cortical distances. He concludes that the separation of his brickwork hallucinations corresponds to the separation of the physiologically active “stripes” in the V2 part of the visual cortex, while the separation of the dots he hallucinates corresponds to that of the “blobs” in the primary visual cortex. Burke hypothesizes that with diminished input from his damaged maculas, there is diminished activity in the macular cortex, releasing spontaneous activity in the cortical stripes and blobs that give rise to hallucinations.

12

I have heard similar descriptions from other people who have both CBS and some dementia. Janet B. likes to listen to audiobooks and sometimes finds herself joined by a hallucinatory group of fellow listeners. They listen intently but never speak, do not respond to her questions, and seem unaware of her presence. At first, Janet realized that they were hallucinatory, but later, as her dementia advanced, she insisted that they were real. Once when her daughter was visiting and said, “Mom, there’s no one here,” she got angry and chased her daughter out.

A more complex delusional overlay occurred while she was listening to a favorite show on television. It seemed to Janet that the television crew had decided to use her apartment, and that it was set up with cables and cameras, that the show was actually being filmed at that moment in front of her. Her daughter happened to telephone her during the show, and Janet whispered, “I have to be quiet — they’re filming.” When her daughter arrived an hour later, Janet insisted that there were still cables all over the floor, adding, “Don’t you see that woman?”

Even though Janet was convinced of the reality of these hallucinations, they were entirely visual. People pointed, gestured, mouthed, but made no sound. Nor did she have any sense of personal involvement; she found herself in the midst of strange happenings, yet they seemed to have nothing to do with her. In this way they retained the typical character of CBS hallucinations, even though she insisted that they were real.

13

While the romantic use of sensory deprivation, as that of vision-producing drugs, has diminished since the 1960s, its political use is still horrifyingly common in the treatment of prisoners. In a 1984 paper on “hostage hallucinations,” Ronald K. Siegel pointed out that such hallucinations can be magnified sometimes to madness, especially when combined with social isolation, sleep deprivation, hunger, thirst, torture, or the threat of death.

14

There may be severe visual impairment or complete blindness without a hint of CBS, and this might seem to imply that visual deprivation alone is not a sufficient cause for it. But we are still ignorant as to why some people with visual problems get CBS and others do not.

15

Molly Birnbaum, an aspiring chef who became anosmic after being struck by a car, has described the anosmic’s predicament eloquently in her memoir Season to Taste.

16

Among these other conditions is infection with the herpes simplex virus, which can attack nerves (including sometimes the olfactory nerves), both impairing and stimulating them. The virus can remain dormant for long periods, sequestered in nerve ganglia, and suddenly reemerge at intervals of months or years. One man, a microbiologist, wrote to me: “In the summer of 2006, I began to ‘smell things,’ a faint pervasive odor that I could not identify (my best guess was … wet cardboard).” Prior to this, he said, “I had a highly sensitive nose, and was able to identify my laboratory cultures by smell alone, or subtle differences in organic solvents, or faint perfumes.”

He soon developed a constant hallucination of the smell of rotting fish, which faded only after a year had passed, along with most of his “olfactory acuity and the subtlety of most foods.” He wrote:

Certain odors are completely gone — feces(!), baking bread, or cookies, roasting turkey, garbage, roses, the fresh soil smell of Streptomyces … all gone. I miss the smells of Thanksgiving, but not the smell of public toilets.

The dysosmia and phantosmia were due to a reemergence of the herpes simplex 2 which he had contracted many years before, and he is intrigued that these are always preceded by hallucinatory smells. He writes, “I smell the onset of herpes reactivation. A day or two prior to the onset of a neuritis episode, I again have olfactory hallucinations of the last strong smell I noticed. [This smell] persists during the neuritis and fades as the neuritis fades.… The strength of the hallucinations is correlated with the severity of the generalized neuritis.”

17

The real patients, however, were more observant. “You’re not crazy,” said one. “You’re a journalist or a professor.”

18

Freud was not unsympathetic to the notion of telepathy; his “Psychoanalysis and Telepathy” was written in 1921, though published only posthumously.

19

Recently, a number of people who hear voices have organized networks in various countries asserting their “right” to hear voices, to have them respected and not dismissed as trivial or pathological. This movement and its significance are discussed by Ivan Leudar and Philip Thomas in their book Voices of Reason, Voices of Madness and by Sandra Escher and Marius Romme in their 2012 review of the subject.

20

Judith Weissman, in her book Of Two Minds: Poets Who Hear Voices, presents strong evidence, drawn especially from what poets themselves have said, that many of them, from Homer to Yeats, have been inspired by true auditory vocal hallucinations, not just metaphorical voices.

21

Jaynes thought that there might be a reversion to “bicamerality” in schizophrenia and some other conditions. Some psychiatrists (such as Nasrallah, 1985) favor this idea or, at the least, the idea that the hallucinatory voices in schizophrenia emanate from the right side of the brain but are not recognized as one’s own, and are thus perceived as alien.

22

Sarah Lipman has noted, in her blog (www.reallysarahsyndication.com), the phenomenon of “phantom rings” as people imagine or hallucinate the ringing of their cell phones. She links this to a state of vigilance, expectation, or anxiety, as when she thinks she may hear a knock at the door or her baby crying. “Part of my consciousness,” she wrote to me, “is straining to monitor for the sound. It seems to me that it is this hyper-alert state that generates the phantom sounds.”

23

There may be paroxysmal musical hallucinations during temporal lobe seizures. But in such cases, the musical hallucinations have a fixed and invariable format; they appear along with other symptoms (perhaps visual or olfactory hallucinations or a sense of déjà vu) and at no other time. If the seizures can be controlled medically or surgically, the epileptic music will cease.

24

Most people who get musical hallucinations are elderly and somewhat deaf; it is not unusual for them to be treated as if demented, psychotic, or imbecilic. Jean G. was hospitalized after she had an apparent heart attack, and a few days later, she began “hearing a male choir in the distance as if it were coming through the woods.” (Several years later, when she wrote to me, she still heard this, especially in times of stress or when she was extremely tired.) But, she said, “I quickly stopped talking about this type of music when faced with a nurse asking me, ‘Do you know your name? Do you know what day this is?’ I responded back, ‘Yes, I know what day this is — it is the day I am going home.’ ”

25

I have written at much greater length about musical hallucinations (as well as intrusive musical imagery, or “earworms”) in my book Musicophilia.

26

My colleague Steven Frucht described to me a hallucination experienced by a patient of his, an intellectually intact woman who has been treated with medications for Parkinson’s disease for more than fifteen years. Her hallucinations, however, started only a year ago. She also sees a cat — a grey cat with “beautiful” eyes which wears a serene, “beautiful expression” on its face and seems to be of a most friendly disposition. To her own surprise (for she has never liked cats), she enjoys visits from the grey cat and worries that “something may happen to him.” Though she knows the cat is a hallucination, he seems very real to her: she can hear him coming, feel the warmth of his body, and touch him if she wishes. The first time the cat appeared, wanting to rub against her legs, she said, “Don’t touch me, don’t get too close.” And since then the cat has kept a decorous distance. Occasionally, in the afternoon, the cat is joined by a large black dog. When Dr. Frucht asked her what happens when the cat sees the dog, she replied that the cat “looks away and is peaceful.” She later remarked, “He is fulfilling his purpose in coming to visit me.”

27

Impairment of the sense of smell may appear early in Parkinson’s disease and may perhaps predispose to smell hallucinations as well. But even in the absence of a noticeable impairment of smell, as Landis and Burkhard suggested in a 2008 paper, patients with incipient Parkinson’s disease may have olfactory hallucinations before they develop motor symptoms.

28

Curiously, lower plants — cycads, conifers, ferns, mosses, and seaweeds — lack hallucinogenic substances.

Some nonflowering plants, however, contain stimulants, as the Mormons, among others, discovered. Mormons are forbidden to use tea or coffee. But on their long march along the Mormon Trail to Utah, the pioneers who were to found Salt Lake City, the new Zion, noticed a simple herb by the roadside, an infusion of which (“Mormon tea”) refreshed and stimulated the weary pilgrims. The herb was ephedra, which contains ephedrine, chemically and pharmacologically akin to the amphetamines.

29

Quite by accident, Hofmann discovered the hallucinogenic powers of LSD when he synthesized a new batch of the chemical in 1943. He must have absorbed some through his fingertips, for later that day he began to feel odd and went home, thinking he had a cold. As he lay in bed, he experienced “an uninterrupted stream of fantastic images of extraordinary plasticity and vividness and accompanied by an intense kaleidoscopic play of colors.” Jay Stevens, in his book Storming Heaven: LSD and the American Dream, recounted what came next:

Suspecting that LSD-25 had caused these fireworks, Hofmann decided to test this hypothesis.… [A few days later] he dissolved what he thought was a prudently infinitesimal amount of the drug — 250 millionths of a gram — in a glass of water and drank it down. [Forty minutes later] he recorded a growing dizziness, some visual disturbance, and a marked desire to laugh. Forty-two words later he stopped writing altogether and asked one of his lab assistants to call a doctor before accompanying him home. Then he climbed onto his bicycle — wartime shortages having made automobiles impractical — and pedaled off into a suddenly anarchic universe.

30

I am quoting from the translation provided by David Ebin in his excellent book The Drug Experience: First-Person Accounts of Addicts, Writers, Scientists, and Others.

31

Louis Lewin, a German pharmacologist, published the first scientific analysis of the peyote cactus in 1886, and it was named Anhalonium lewinii in his honor. Later, he sought to classify various psychoactive substances based on their pharmacological effects, and he divided them into five general groups: euphoriants or sedatives (like opium), inebriants (like alcohol), hypnotics (like chloral and kava), excitants (like amphetamine and coffee), and hallucinogens, which he called phantastica. Many drugs, he noted, had overlapping and paradoxical effects, so that stimulants or sedatives could sometimes be as hallucinogenic as peyote.

32

Benny Shanon uses this phrase as the title of his remarkable book The Antipodes of the Mind, which is based on personal experience as well as extensive cultural and anthropological experience with the South American hallucinogen ayahuasca. Ayahuasca is, in fact, a blend of two plants: Psychotria viridis and Banisteriopsis caapi, neither of which has any hallucinogenic power by itself. The leaves of Psychotria contain dimethyltryptamine (DMT), a very powerful hallucinogen — but DMT, if taken by mouth, is deactivated in the gut by monoamine oxidase (MAO). Banisteriopsis, however, contains compounds that inhibit the MAO and so allow the DMT to be absorbed. “When one thinks about it,” Shanon writes, “the discovery of Ayahuasca is indeed amazing. The number of plants in the rain forest is enormous, the number of their possible pairings astronomical. The common sense method of trial and error would not seem to apply.”

33

Breslaw’s account is included in David Ebin’s book The Drug Experience.

34

I have discussed neurological aspects of time and motion perception, as well as cinematic vision, at greater length in two articles, “Speed” and “In the River of Consciousness.”

35

Very little was known in the early 1960s about how psychoactive drugs worked, and early research by Timothy Leary and others at Harvard, as well as the work of L. Jolyon West and Ronald K. Siegel at UCLA in the 1970s, focused mostly on the experiences of hallucinogens rather than their mechanisms. In 1975, Siegel and West published a wide-ranging collection of essays in their book Hallucinations: Behavior, Experience, and Theory. Here West set out (as he had in previous work) his release theory of hallucination.

It is now known that stimulants like cocaine and the amphetamines stimulate the “reward systems” of the brain, which are largely mediated by the neurotransmitter dopamine; this is also the case with opiates and alcohol. The classical hallucinogens — mescaline, psilocybin, LSD, and probably DMT — act by boosting serotonin in the brain.

36

When, decades later, I told this story to my friend Tom Eisner, an entomologist, I mentioned the spider’s philosophical tendencies and Russellian voice. He nodded sagely and said, “Yes, I know the species.”

37

Many years later, I experienced the much gentler effects of sakau, the intoxicating sap of a pepper (Piper methysticum, also called kava in Polynesia) cultivated in the South Pacific. Drinking sakau has been a central part of Micronesian life, as chewing coca leaves has been in the Andes, for thousands of years; and its use is formalized in elaborate sakau rituals. I described the effects of sakau at length in The Island of the Colorblind; it may evoke a delicious sense of floating and ease, as well as a variety of visual illusions or hallucinations.

38

A migraine headache often occurs on only one side (hence the term, which derives from the Greek for “hemi” and “cranium”). But it can also be on both sides, and can range from a dull or throbbing ache to excruciating pain, as J. C. Peters described in his 1853 A Treatise on Headache:

The character of the pains varied very much; most frequently they were of a hammering, throbbing or pushing nature.… [in other cases] pressing and dull … boring with sense of bursting … pricking … rending … stretching … piercing … and radiating.… In a few cases it felt as if a wedge was pressed into the head, or like an ulcer, or as if the brain was torn, or pressed outwards.

39

This woman, Ingrid K., also reported that she sometimes has “another strange experience just before the migraine … I think I recognize everyone I see. I don’t know who they are … but everyone looks familiar.” Other correspondents have described a similar “hyperfamiliarity” at the start of migraine — and this feeling is occasionally part of an epileptic aura, as Orrin Devinsky and his colleagues have described.

40

When Hippocrates wrote “On the Sacred Disease,” he was bowing to the then-popular notion of epilepsy’s divine origin, but he dismisses this in his opening sentence: “The disease called sacred … appears to me no more sacred than other diseases, but has a natural cause from which it originates, like other affections.”

41

Beginning in 1861, when he was twenty-four, Hughlings Jackson published many major papers — on epilepsy, aphasia, and other subjects, as well as what he called “evolution and dissolution in the nervous system.” A selection of these, filling two large volumes, was published in 1931, twenty years after his death. In his later years, Jackson published a series of twenty-one short, gemlike papers in the Lancet under the title Neurological Fragments. These were collected and published in book form in 1925.

42

David Ferrier, a contemporary of Gowers’s, moved to London in 1870, where he was mentored by Hughlings Jackson (Ferrier became a great experimental neurologist in his own right — he was the first to use electrical stimulation to map the monkey’s brain). One of Ferrier’s epileptic patients had a remarkable synesthetic aura, in which she would experience “a smell like that of green thunder.” (This is quoted by Macdonald Critchley in his 1939 paper on visual and auditory hallucinations.)

43

Hughlings Jackson described such seizures in 1875 and thought they might originate from a structure in the brain located beneath the olfactory cortex, the uncinate gyrus. In 1898 Jackson and W. S. Colman were able to confirm this by autopsy in Dr. Z., a patient who had died of an overdose of chloral hydrate. (More recently, David C. Taylor and Susan M. Marsh have recounted the fascinating history of Dr. Z., an eminent physician named Arthur Thomas Myers whose brother, F. W. H. Myers, had founded the Society for Psychical Research.)

44

In the 1946 film A Matter of Life and Death (called Stairway to Heaven in the United States), David Niven’s character, a pilot, has complex epileptic visions that are always preceded by an olfactory hallucination (the smell of burnt onions) and a musical one (a recurrent theme of six notes). Diane Friedman has written a fascinating book about this, indicating how meticulous the director, Michael Powell, was in consulting neurologists about the forms of epileptic hallucinations.

45

Penfield was a great physiologist as well as a neurosurgeon, and in the process of searching for epileptic foci, he was able to map most of the basic functions of the living human brain. He showed, for example, exactly where sensations and movements of specific body parts were represented in the cerebral cortex — his sensory and motor homunculi are iconic. Like Weir Mitchell, Penfield was an engaging writer, and after he and Herbert Jasper published their magnum opus, Epilepsy and the Functional Anatomy of the Human Brain, in 1958, he continued to write about the brain, as well as writing novels and biographies, until his death at eighty-six.

46

For Gowers and his contemporaries in the early twentieth century, memories were imprints in the brain (as for Socrates they were analogous to impressions made in soft wax) — imprints that could be activated by the act of recollection. It was not until the crucial studies of Frederic Bartlett at Cambridge in the 1920s and 1930s that this classical view could be disputed. Whereas Ebbinghaus and other early investigators had studied rote memory — how many digits could be remembered, for instance — Bartlett presented his subjects with pictures or stories and then questioned and requestioned them over a period of months. Their accounts of what they had seen or heard were somewhat different (and sometimes quite transformed) on each re-remembering. These experiments convinced Bartlett to think in terms not of a static thing called “memory,” but rather a dynamic process of “remembering.” He wrote:

Remembering is not the re-excitation of innumerable fixed, lifeless and fragmentary traces. It is an imaginative reconstruction, or construction, built out of the relation of our attitude towards a whole active mass of organized past reactions or experience.… It is thus hardly ever really exact.

47

Penfield sometimes used the term “flashback” for experiential hallucinations. The term is also used in quite different contexts, as in post-traumatic flashbacks, where there are recurrent hallucinatory replayings of traumatic events.

The term “flashback” is also used for a sudden, transient reexperiencing of a drug effect — suddenly feeling, for example, the effects of LSD, even though one has not taken it for months.

48

One such patient, who had very little in the way of religious interests as an adult, had his first religious seizure at a picnic, as Devinsky described to me: “His friends observed at first that he stared, became pale, and was unresponsive. Then suddenly, he began to run in circles for two or three minutes yelling, ‘I am free! I am free!… I am Jesus! I am Jesus!’ ”

The patient later had a similar seizure which was recorded on video EEG, and, just before the seizure, Devinsky noted, the patient was slow to respond and disoriented regarding time and place:

When asked if there was anything wrong, he replied: “nothing is wrong, I am doing well … I am very happy” and when asked whether he knew where he was, he replied with a smile and a surprised look: “Of course I know. I am in heaven right now;… I am fine.”

He remained in this state for ten minutes, then went on to a generalized seizure. Later, he remembered his ecstatic aura “as if it were a vivid and happy dream” from which he had now awoken, but he had no memory of the questions put to him during the aura.

49

She ran as a Republican in a district that had been Democratic for a very long time, and lost by only a narrow margin. Whenever she appeared in public during her campaign, she said that God had told her to run, and this apparently persuaded thousands of people to vote for her, despite her manifest lack of political experience or skills.

50

The evidence here has been discussed in a number of books, including Kevin Nelson’s The Spiritual Doorway in the Brain: A Neurologist’s Search for the God Experience. It is also the theme of a novel, Lying Awake, by Mark Salzman; the protagonist is a nun who has ecstatic seizures in which she communes with God. Her seizures, it turns out, are caused by a tumor in her temporal lobe, and it must be removed before it enlarges and kills her. But will its removal also remove her portal to heaven, preventing her from ever communing with God again?

51

Before seeing Ellen O., I had never heard of visual perseveration of such duration. Visual perseveration of a few minutes may be associated with cerebral tumors of the parietal or temporal lobes or may occur in temporal lobe epilepsy. There are a number of such accounts in the medical literature, including one by Michael Swash, who described two people with temporal lobe epilepsy. One of them had attacks in which “his vision seemed to become fixed, so that an image was retained for several minutes. During these episodes the real world was seen through the retained image, which was clear at first, but then gradually faded.”

Similar perseveration may occur with damage or surgery to an eye. My correspondent H.S. was blinded by a chemical explosion at the age of fifteen but had some sight restored by corneal surgery twenty years later. Following the operation, when his surgeon asked if he could now see the surgeon’s hand, H.S. replied, “Yes” — but then was astonished to see the hand, or its image, preserving its exact shape and position, for several minutes afterward.

52

In a letter to me, James Lance commented, “I have never encountered hallucination embracing information from the surroundings like Mr. H.’s.”

53

In addition to the overt delirium that may be associated with life-threatening medical problems, it is not uncommon for people to have slight delirium, so mild that it would not occur to them to consult a physician, and which they themselves may disregard or forget. Gowers, in 1907, wrote that migraine is “often attended by quiet delirium of which nothing can be subsequently recalled.”

There has always been inconsistency in defining delirium, and as Dimitrios Adamis and his colleagues pointed out in their review of the subject, it has frequently been confused with dementia and other conditions. Hippocrates, they wrote, “used about sixteen words to refer to and name the clinical syndrome which we now call delirium.” There was additional confusion with the medicalization of insanity in the nineteenth century, as German Berrios has noted, so that insanity was referred to as délire chronique. Even now the terminology is ambiguous, so that delirium is sometimes called “toxic psychosis.”

54

Just such an appearance of delirious images when closing the eyes, and their disappearance when the eyes are opened, is described by John Maynard Keynes in his memoir “Dr. Melchior”:

By the time we were back in Paris, I was feeling extremely unwell and took to my bed two days later. High fever followed.… I lay in my suite in the Majestic, nearly delirious, and the image of the raised pattern on the nouveau art wall-paper so preyed on my sensibilities in the dark that it was a relief to switch on the light and, by perceiving the reality, to be relieved for a moment from the yet more hideous pressure of its imagined outlines.

55

In a prefatory note to a later edition, Waugh wrote: “Three years ago Mr. Waugh suffered a brief bout of hallucinations resembling what is here described.… Mr. Waugh does not deny that ‘Mr. Pinfold’ is largely based on himself.” Thus we may accept The Ordeal as an autobiographic “case history” of a psychosis, an organic psychosis, albeit one written with a mastery of observation and description — and a sense of plot and suspense — that no purely medical case history has.

W. H. Auden once said that Waugh had “learned nothing” from his ordeal, but it at least enabled him to write a richly comic memoir, a new departure quite unlike anything he had written previously.

56

The Reverend Henslow was a son of the botanist John Stevens Henslow, who was Darwin’s teacher at Cambridge and was instrumental in getting him a position aboard the Beagle.

57

Feeling that hypnagogic hallucinations could extend and enrich the imagination, Poe would jerk himself suddenly to full wakefulness while hallucinating, so that he could make note of the extraordinary things he saw, and he often brought these into his poems and short stories. Poe’s great translator, Baudelaire, was also fascinated by the unique quality of such visions, especially if they were potentiated by opium or hashish. A whole generation in the early nineteenth century (including Coleridge and Wordsworth, as well as Southey and De Quincey) was influenced by such hallucinations. This is explored by Alethea Hayter in her book Opium and the Romantic Imagination and by Eva Brann in her magisterial The World of the Imagination: Sum and Substance.

58

Hypnopompic hallucinations are far less common than hypnagogic ones, and some people have hypnagogic hallucinations upon awakening, or hypnopompic ones while falling asleep.

59

Spinoza, in the 1660s, described a similar hallucination in a letter to his friend Peter Balling:

When one morning, after the day had dawned, I woke up from a very unpleasant dream, the images, which had presented themselves to me in sleep, remained before my eyes just as vividly as though the things had been real, especially the image of a certain black and leprous Brazilian whom I had never seen before. This image disappeared for the most part when, in order to divert my thoughts, I cast my eyes on a book or something else. But as soon as I lifted my eyes again, without fixing my attention on any particular object, the same image of this same negro appeared with the same vividness again and again, until the head of it finally vanished.

60

Bill Hayes, in his book Sleep Demons, cites an even earlier reference to irresistible, overwhelming sleepiness and probable cataplexy — “It falls upon them in the midst of mirth” — from a little-known 1834 book, The Philosophy of Sleep, by the Scottish physician Robert Macnish.

61

A key figure in the narcolepsy world is Michael Thorpy, a physician whose many books on narcolepsy and other sleep disorders have grown out of a lifetime of experience directing a sleep disorders clinic at Montefiore Medical Center in the Bronx.

62

This simple equation had to be modified later, when it was found that dreams — albeit of a somewhat different kind — could also occur in non-REM sleep.

63

Many of H. G. Wells’s short stories also involve guilt hallucinations. In “The Moth,” a zoologist who feels himself responsible for the death of his lifelong rival is haunted and finally driven mad by a giant moth that no one else can see, a moth of a genus unknown to science; but in his lucid moments, he jokes that it is the ghost of his deceased rival.

Dickens, a haunted man himself, wrote five books on this theme, the best known of these being A Christmas Carol. And in Great Expectations, he provides a dramatic account of Pip’s vision after his first, horrified encounter with Miss Havisham:

I thought it a strange thing then, and I thought it a stranger thing long afterwards. I turned my eyes — a little dimmed by looking up at the frosty light — towards a great wooden beam in a low nook of the building near me on my right hand, and I saw a figure hanging there by the neck. A figure all in yellow white, with but one shoe to the feet; and it hung so that I could see that the faded trimmings of the dress were like earthy paper, and that the face was Miss Havisham’s, with a movement going over the whole countenance as if she were trying to call me. In the terror of seeing the figure, and in the terror of being certain that it had not been there a moment before, I at first ran from it, and then ran towards it. And my terror was greatest of all when I found no figure there.

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Losing a spouse, of course, is one of the most stressful of life events, but bereavement may happen in many other situations, from the loss of a job to the loss of a beloved pet. A friend of mine was very upset when her twenty-year-old cat died, and for months she “saw” the cat and its characteristic movements in the folds of the curtains.

Another friend, Malonnie K., described a different sort of cat hallucination, after her beloved seventeen-year-old pet died:

Much to my surprise, the next day I was getting ready for work and she appeared at the bathroom door, smiled and meowed her usual “good morning.” I was flabbergasted. I went to tell my husband and when I returned, of course, she was no longer there. This was upsetting to me because I have no history of hallucinations and thought I was “above” such things. However, I have accepted that this experience was, perhaps, a result of the phenomenally close bond that we had developed and sustained over nearly two decades. I must say, I am so grateful that she stopped by one last time.

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Loss, longing, and nostalgia for lost worlds are also potent inducers of hallucinations. Franco Magnani, “the memory artist” I described in An Anthropologist on Mars, had been exiled from Pontito, the little village where he grew up, and although he had not returned to it in decades, he was haunted by continual dreams and hallucinations of Pontito — an idealized, timeless Pontito, as it looked before it was invaded by the Nazis in 1943. He devoted his life to objectifying these hallucinations in hundreds of nostalgic, beautiful, and uncannily accurate paintings.

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Though “flashback” is a visual, cinematic term, auditory hallucinations can be very striking, too. Veterans with PTSD may hallucinate the voices of dying comrades, enemy soldiers, or civilians. Holmes and Tinnin, in one study, found that the hearing of intrusive voices, explicitly or implicitly accusing, affected more than 65 percent of veterans with combat PTSD.

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Sometimes this effect can be heightened by medications. In 1970, I had one patient with postencephalitic parkinsonism who was a concentration camp survivor. For her, treatment with L-dopa caused an intolerable exacerbation of her traumatic nightmares and flashbacks, and we had to discontinue the drug.

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In the “normal” neuroses commonly brought to psychotherapists, the buried, pathogenic material typically comes from much earlier in life. Such patients are also haunted, but as in the title of Leonard Shengold’s book, they are Haunted by Parents.

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Freud was deeply puzzled and troubled by the pertinacity of such post-traumatic syndromes after World War I. Indeed, they forced him to question his theory of the pleasure principle and, at least in this case, to see instead a much grimmer principle at work, that of repetition-compulsion, even though this seemed maladaptive, the very antithesis of a healing process.

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Many of the testimonies and accusations in the Salem witch trials described assaults by hags, demons, witches, or cats (which were seen as witches’ familiars). The cats would sit astride sleepers, pressing on their chests, suffocating them, while the sleepers had no power to move or resist. These are experiences we would now interpret in terms of sleep paralysis and night-mare, but which were given a supernatural narrative. The whole subject is explored by Owen Davies in his 2003 article “The Nightmare Experience, Sleep Paralysis, and Witchcraft Accusations.”

Other conditions have also been suggested as contributing to the hallucinations and hysteria of seventeenth-century New En gland. One hypothesis, which Laurie Winn Carlson proposes in her book A Fever in Salem, sees the madness as a manifestation of a postencephalitic disorder.

Others have proposed that ergot poisoning played a part. Ergot, a fungus containing toxic alkaloid compounds similar to LSD, can infest rye and other grains, and if contaminated bread or flour is eaten, ergotism may result. This happened frequently in the Middle Ages, and it could cause agonizing gangrene (which led to one of its popular names, St. Anthony’s fire). Ergotism could also cause convulsions and hallucinations very similar to those of LSD.

In 1951, an entire French village succumbed to ergot poisoning, as John Grant Fuller described in his book The Day of St. Anthony’s Fire. Those affected endured several weeks of terrifying hallucinations and often compulsions to jump from windows, as well as extreme insomnia.

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This was shown experimentally by Brady and Levitt in a 1966 study, in which they suggested to hypnotized subjects that they “see” (i.e., hallucinate) a moving visual stimulus (a rotating drum with vertical stripes). The subjects’ eyes, as they did this, showed the same automatic tracking movements (“optokinetic nystagmus”) that occur when one is actually looking at such a rotating drum — whereas no such movements occur (and they are impossible to feign) if one merely imagines such a visual target.

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The term “out-of-body experience” was introduced in the 1960s by Celia Green, an Oxford psychologist. While there had been stories of out-of-body experiences for centuries, Green was the first to systematically examine a large number of firsthand accounts, from more than four hundred people whom she located by launching a public appeal through the newspapers and the BBC. In her 1968 book, Out-of-the-Body Experiences, she analyzed these in detail.

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Several of Celia Green’s subjects described similar feelings. “My mind was clearer and more active than before,” one wrote; another spoke of being “all-knowing and understanding.” Green wrote that such subjects felt they “could obtain an answer to any question they chose to formulate.”

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August Strindberg noted, in his autobiographical novel Inferno, an odd body double, an “other” who mirrored his every movement.

This unknown man never uttered a word; he seemed to be occupied in writing something behind the wooden partition that separated us. All the same, it was odd that he should push back his chair every time I moved mine. He repeated my every movement in a way that suggested that he wanted to annoy me by imitating me. … When I went to bed the man in the room next to my desk went to bed too. … I could hear him lying there, stretched out parallel to me. I could hear him turning the pages of a book, putting out the lamp, breathing deeply, turning over and falling asleep.

Strindberg’s “unknown man” is identical with Strindberg in one sense: a projection of him, at least of his movements, his actions, his body image. Yet, at the same, he is someone else, an Other who occasionally “annoys” Strindberg, but perhaps, at other times, seeks to be companionable. He is, in the literal sense of the term, Strindberg’s “Other,” his “alter ego.”

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It is likely that there was popular or folk knowledge of the phenomenon long before there were any medical descriptions.

Twenty years before Weir Mitchell named phantom limbs, Herman Melville included a fascinating scene in Moby-Dick, where the ship’s carpenter is measuring Captain Ahab for a whalebone leg. Ahab addresses the carpenter:

Look ye, carpenter, I dare say thou callest thyself a right good workmanlike workman, eh? Well, then, will it speak thoroughly well for thy work, if, when I come to mount this leg thou makest, I shall nevertheless feel another leg in the same identical place with it; that is, carpenter, my old lost leg; the flesh and blood one, I mean. Canst thou not drive that old Adam away?

[The carpenter replies:] Truly, sir, I begin to understand somewhat now. Yes, I have heard something curious on that score, sir; how that a dismasted man never entirely loses the feeling of his old spar, but it will be still pricking him at times. May I humbly ask if it be really so, sir?

It is, man [says Ahab]. Look, put thy live leg here in place where mine once was; so, now, here is only one distinct leg to the eye, yet two to the soul. Where thou feelest tingling life; there, exactly there, there to a hair, do I.

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The importance of first-person accounts was emphasized by William James in his 1887 paper “The Consciousness of Lost Limbs”:

In a delicate inquiry like this, little is to be gained by distributing circulars. A single patient with the right sort of lesion and a scientific mind, carefully cross-examined, is more likely to deepen our knowledge than a thousand circulars answered as the average patient answers them, even though the answers be never so thoroughly collated by the investigator.

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The reason for this was not to be clarified until a century later, when it became possible to visualize, with fMRI, the gross changes in the brain’s body mapping that could occur after an amputation. Michael Merzenich and his colleagues at UCSF, working with both monkeys and humans, have shown how rapid and radical such changes may be.

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Despite categorical assertions by many that “congenital” phantoms cannot occur, there have been several reports (as Scatena has noted in a review of the subject) indicating that some people with aplasia — congenitally defective or absent limbs — do have phantoms. Klaus Poeck, in 1964, described an eleven-year-old girl born without forearms or hands who was able to “move” her phantom hands. As Poeck wrote, “In her first years at school, she had learned to solve simple arithmetic problems by counting with her fingers.… On these occasions she would place her phantom hands on the table and count the outstretched fingers one by one.”

It is not clear why some people born without limbs have phantoms and some do not. What is clear, as Funk, Shiffrar, and Brugger observed in one study, is that those who do have phantoms seem to have cerebral “action observation systems” similar to those of normally limbed people, allowing them to grasp action patterns by observing others and to internalize these as mobile phantoms. Those born without limbs who do not have phantoms, Funk et al. propose, may have problems in motion perception, especially judging the movements of other people’s limbs.

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When Henry Head introduced the term “body image” (fifty or so years after Weir Mitchell had introduced the term “phantom limb”), he did not mean it to refer to a purely sensory image or map in the brain — he had in mind an image or model of agency and action, and it is this which needs to be embodied in an artificial limb.

Philosophers like to speak of “embodiment” and “embodied agency,” and there is no simpler place to study this than in the nature of phantoms and their embodiment in artificial limbs — prosthesis and phantom go together like body and soul. I have wondered whether some of Ludwig Wittgenstein’s philosophical notions were suggested by his brother’s phantom arm — thus his final work, On Certainty, starts from the certainty of the body, the body as embodied agency.

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Wade Davis describes this in his book Into the Silence: The Great War, Mallory, and the Conquest of Everest.

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Nonetheless, Nelson regarded his phantom as “a direct proof for the existence of the soul.” The survival of a spiritual arm after a corporeal one was annihilated, he thought, epitomized the survival of the soul after bodily death.

For Captain Ahab, however, this was a matter for horror as much as wonder: “And if I still feel the smart of my crushed leg, though it be now so long dissolved; then, why mayst not thou, carpenter, feel the fiery pains of hell forever, and without a body? Hah!”

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This story, “The Man Who Fell Out of Bed,” is related more fully in The Man Who Mistook His Wife for a Hat.

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Several people have written to me with similar stories of sensing a presence just as they are going to sleep or waking. Linda P. observed that once, as she was drifting off to sleep, she felt “as if I was being held on my right side, as if someone had put their arms around me and was stroking my hair. It was a lovely feeling; then I remembered that I was alone, and [the feeling disappeared].”