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Hallucinations: The Science of Idiosyncratic

Perception Hardcover
by Andre Aleman (Author), Frank Laroi (Author)
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Cover
Beginning
 Hallucinations
The Science of Idiosyncratic Perception

André Aleman and Frank Larøi

 American Psychological Association
Washington, DC
Copyright © 2008 by the American Psychological Association. All rights reserved. Except as
permitted under the United States Copyright Act of 1976, no part of this publication may be
reproduced or distributed in any form or by any means, including, but not limited to, the process of
scanning and digitization, or stored in a database or retrieval system, without the prior written
permission of the publisher.
Electronic edition published 2013.
ISBN: 978-1-4338-1405-1 (electronic edition).
Published by
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Washington, DC 20002
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The opinions and statements published are the responsibility of the authors, and such opinions and
statements do not necessarily represent the policies of the American Psychological Association.
Library of Congress Cataloging-in-Publication Data
Aleman, André.
   Hallucinations : the science of idiosyncratic perception / André Aleman and Frank Larøi. — 1st ed.
       p. ; cm.
   Includes bibliographical references and index.
   ISBN-13: 978-1-4338-0311-6
   ISBN-10: 1-4338-0311-9
  1. Hallucinations and illusions. I. Larøi, Frank. II. American Psychological Association. III. Title.
    [DNLM: 1. Hallucinations. 2. Cognition. WM 204 A367h 2008]
   RC553.H3A44 2008
   616.8—dc22
2007033125        
British Library Cataloguing-in-Publication Data
A CIP record is available from the British Library.
First Edition
Til Jørgen og Johann. Hva i all verden skulle jeg giort uten dere! To Jørgen and Johann. What in the
world would I have done without you!

CONTENTS
Introduction
Chapter 1.    Definition and Conceptual Issues
Chapter 2.    The Phenomenology of Hallucinations
Chapter 3.    Groups of Hallucinators
Chapter 4.    Cognitive–Perceptual Processes: Bottom-Up and Top-Down
Chapter 5.    Metacognitive Processes: Reality Monitoring and
Metacognitive Beliefs
Chapter 6.    Hallucinations and the Brain
Chapter 7.    Toward a Comprehensive Model
Chapter 8.    Treatment of Hallucinations
Appendix:    Assessment Instruments for Hallucinations
References
About the Authors

Hallucinations

INTRODUCTION
Hallucinations are an intriguing psychological phenomenon. A person
perceives something: a sound, a voice, an image. However, there is no
corresponding source in the outside world. How can a person who took
LSD see vivid objects when no corresponding photons hit the eye? Or how
can a patient with schizophrenia hear people conversing about him loudly
and clearly when no sound waves are registered by his ears? Hallucinations
can occur in several medical conditions, including psychiatric disorders, but
they can also arise because of the intake of a variety of substances, such as
LSD or PCP (Brasić, 1998; Slade & Bentall, 1988). Further, hallucinations
have also been reported in healthy people from the nonpatient population
(Johns & van Os, 2001). The riddle of how hallucinations come about has
puzzled clinicians, researchers, and laypeople alike.
Hallucinations are not only an intellectual mystery but also frequently a
clinical problem. They can be severely distressing and disruptive of normal
functioning. This is vividly illustrated by an excerpt from a first-person
account by a woman who was hospitalized several times with severe
psychosis. After describing some initial delusional and hallucinatory
experiences, she wrote the following:
The next day I am listening to the soundtrack of the film The Hurricane, as I clean my apartment.
Suddenly there is an excruciating pain in my head. It is as if sandpaper were being pulled across the
surface of my brain. I hear nasty voices: “You little dumb *** bitch think you can hang out with your
special friends. We are here to teach you otherwise. You New World people we can’t stand your guts
you’re all such a bunch of phonies. We’re the white lighting [sic] people the Tellurian Hounds and
once we’re finished with you, you won’t recognize the world you live in.” I can’t stand these voices, the
bemoaning belittling laughs. What is going on? I am devastated…. “We’re going to do some work on
your brain Yvonne. You like the Hurricane huh? We can’t stand these good black people. You think
you’ve accomplished something getting white lightning out of your toilet bowl, try getting it out of
your head.” The most brutish roaring laughter follows. I am distraught. I run up and down the hallway
of my apartment. I can’t believe what is happening. I pull my hair. It can’t be true what these voices
are saying. I try to hide my head, between cushions, between objects, tables, chairs, inside a chest of
drawers, anywhere, any place in the apartment, to make the voices stop. But they don’t. (Writing:
Hallucinations, n.d.)

WHO IS THIS BOOK FOR?

This book is written for researchers, clinicians, and students with a
background in psychology, psychiatry, cognitive neuroscience, neurology,
social work, or philosophy. In fact, it may appeal to any reader interested in
hallucinations and how these originate in the mind and brain. For
clinicians, the discussion of novel approaches to treatment will extend their
“tool kit.” Researchers and students will find not only a comprehensive,
empirically based review of hallucinogenic phenomena but also proposals
for integration of current theory and findings and directions for future
research.

WHAT IS IN THIS BOOK?

The purpose of this book is to bring together current knowledge from
psychological and neuroscience research into hallucinations and thereby
provide a state-of-the-art overview. To this end, we review and integrate all
major findings regarding epidemiology, phenomenology, cognitive
processing, emotional factors, neurochemistry, brain imaging, and
treatment of hallucinations. We intend to cover hallucinations in different
sensory modalities and in different clinical and nonclinical groups. Besides
discussing conceptual issues, we also review the epidemiology and
phenomenology of hallucinations in different sensory modalities. In
addition, studies investigating cognitive processes such as attention,
perception, and memory in relation to hallucinations are discussed, and we
outline the neural basis of hallucinations, drawing on evidence from
neurology and brain imaging. Detailed attention is paid to hallucination
characteristics in the psychoses, although hallucinations associated with
other clinical groups and conditions (e.g., brain damage, Charles Bonnet
syndrome, drugs) are also discussed. The book not only summarizes recent
progress in understanding the cognitive and neural basis of hallucinations
but also describes novel treatments and future research avenues. Finally,
the book moves beyond a critical overview of current research and findings
and proposes an integrative framework that may help in the understanding
of hallucinations and may guide future research.
The approach we have adopted in writing this book can broadly be
defined as being multidisciplinary. More specifically, we start from a
psychological approach, with emphasis on single symptoms as the unit of
analysis and consistent with the cognitive neuropsychiatry approach. We
discuss these interrelated and complementary approaches in turn.
 PSYCHOLOGICAL APPROACH
The psychological approach emphasizes mechanisms common to both
“normal” perception and hallucinations but at the same time specifies what
factors lead to the emergence of the latter. Thus, in our view, hallucinations
are not by definition discontinuous with normal perception. The approach
takes into account cognitive factors underlying perception and also
acknowledges the role of emotion and motivation. In our view, that part of
contemporary psychology that is concerned with the science of the mind-
brain and behavior can be seen as part of the cognitive neurosciences. In
this area of enquiry, psychologists strongly cooperate with researchers and
clinicians from disciplines such as neurophysiology, neurology, and
psychiatry. We have therefore also integrated findings from these fields into
our book.
In our psychological approach, we focus on a single symptom. In
psychiatry and neurology, researchers frequently focus their investigations
on syndromes, that is, particular collections of symptoms that have been
described under a clinical category, such as Alzheimer’s disease, epilepsy,
or schizophrenia. There are some disadvantages to this approach, however,
which are especially apparent in psychiatry. The main problem is the
heterogeneity of syndromes. For example, although hallucinations feature
as a prominent symptom of schizophrenia in the widely used classification
manual, Diagnostic and Statistical Manual of Mental Disorders (4th ed.;
American Psychiatric Association, 1994), not every patient with
schizophrenia experiences hallucinations. The diagnosis can also be made
on the basis of delusions and negative symptoms (apathy, emotional
blunting, and social withdrawal). It is hard to imagine that an explanation
involving one mechanism will suffice to help one understand emotional
blunting and social withdrawal on one hand and also account for
hallucinations and delusions on the other.
The symptom-oriented approach argues that to understand the nature of
the psychological processes underlying phenomena or symptoms, research
should concentrate directly on these individual phenomena (e.g.,
hallucinations) and not on diagnostic categories (e.g., schizophrenia). There
are a number of advantages associated with this approach, but there are
also disadvantages. Some of these are presented and discussed in this
volume; however, for more detailed information concerning this
(interminable) debate, the reader may refer to the specific references.
Persons (1986) provided six important advantages of the symptom
approach. First, it avoids misclassification and confounding, which can
occur with the diagnostic-category design (e.g., not all schizophrenia
patients have hallucinations, and nonschizophrenic patients may also
experience hallucinations). Second, it enables the study of important
phenomena that are ignored by the diagnostic-category design. Third, there
is a greater facilitation of theoretical development (e.g., symptom-specific
theories are clearer and easier to test). Fourth, it permits the isolation of
single elements of pathology for study. Fifth, it recognizes the continuity of
clinical phenomena with normal phenomena and mechanisms. Sixth, it is
less vulnerable to the lack of adequate reliability and validity of diagnostic
categories. In addition to these arguments, C. G. Costello (1992) added two
more arguments in favor of a single-symptom approach: Useful animal
models of symptoms are more likely to be developed, and symptoms may
be better phenotypes than syndromes and thus more amenable to genetic
research.
Mojtabai and Rieder (1998) critically reviewed the arguments in favor of
a symptom-oriented approach compared with a syndrome and/or
diagnostic category-oriented approach, arguing that there is little or no
evidence supporting some of the major assumptions of a symptom-oriented
approach. For example, they presented evidence showing that symptoms do
not necessarily have higher reliability and validity than syndromes or
diagnostic categories. They also argued that some underlying pathological
processes are not exclusively symptom specific (e.g., mechanisms
underlying hallucinations in schizophrenia may be different from those in
hallucinations observed in neurological disorders). Finally, they provided
examples in which an understanding of the etiology of diagnostic categories
or syndromes did not precede an understanding of symptoms. They
concluded that each approach has different aims and answers different
questions and, therefore, should be seen as complementary.

COGNITIVE NEUROPSYCHIATRIC
APPROACH
A cognitive neuropsychiatric approach is also adopted in this book
(David, 1993; Halligan & David, 2001). This approach also takes single
symptoms as its unit of analysis, but in particular, it aims to uncover
abnormalities or dysfunctions in cognitive mechanisms that may account
for the clinical phenomena. Furthermore, the neural basis of such cognitive
alterations is investigated. Thus, three levels of explanation are
distinguished and related to each other (see Mortimer & McKenna, 1994):
phenomenology (the symptom to be understood), cognition (mental
processes), and neurophysiology (the brain correlates). This approach
assumes that the cognitive level is intermediate between symptoms and
neurophysiology and that the neuropsychology of hallucinations may thus
have the potential to connect neuroscience with phenomenology. In this
book, we take a cognitive neuropsychiatry approach by focusing on one
single phenomenon, hallucinations, and by investigating cognitive
processes that might be involved together with their corresponding neural
basis.
 TOWARD A UNIFYING ACCOUNT
Hallucinations can take myriad appearances, as we review in the chapter
on phenomenology (chap. 2). For example, whereas visual hallucinations
predominate in neurological conditions, auditory hallucinations
predominate in a number of psychiatric conditions. Drug-induced
hallucinations tend to be visual but might also be auditory or
somatosensory. With regard to underlying mechanisms of all these
different types of hallucinations, we adopt the stance taken by David (2004)
that in each case, hallucinations of different classes have their unique
pathophysiologies but additionally involve generic mechanisms that render
the individual vulnerable to hallucinations per se. David suggested that
such generic mechanisms may operate in a dose-related manner. Such
mechanisms could be of a physiological nature (e.g., arousal), of a more
psychological nature (e.g., top-down perceptual factors), or an interaction
of these.

OUTLINE OF A COGNITIVE MODEL

To give a preliminary impression of the key components involved, we
provide a brief outline of our cognitive model here. Chapters
1 through 6 provide extensive background information in addition to a
thorough discussion of different cognitive approaches in the literature.
After presenting evidence from dozens of empirical studies, we describe our
model, which integrates a number of ideas and suggestions put forward by
other investigators (whose work is cited accordingly), in more detail
in chapter 7.
In short, our model presumes that a sensory experience (either
perception due to external input or hallucination due to internal input) can
be induced by activation of sensory cortical areas (either primary or
secondary). In normal perception, signals emanating from the sensory
organs play a decisive role, whereas in imagery and hallucinations,
internally generated signals (emanating from cortical centers) play a
decisive role in determining the final “percept.” Interactions between
sensory signals and top-down signals abound, and it is thus very well
possible that external perception triggers hallucination in certain
individuals (e.g., some patients with schizophrenia have reported hearing
voices when the vacuum cleaner was switched on).
The activation in primary and/or secondary sensory brain areas can be
due to input from the senses, lesions to perceptual areas, or input from
higher brain centers. The model posits key roles for (a) attention, (b)
emotion and motivation, (c) top-down perceptual factors, and (d)
monitoring mechanisms. Attention refers to the selective focusing on
particular inputs, thoughts, or actions while ignoring irrelevant or
distracting ones (Gazzaniga, Ivry, & Mangun, 2002). Emotion and
motivation refers to internal desires and goals. Top-down perceptual
factors refers to prior knowledge and expectations that affect perception
and may involve the mental recreation of a sensory experience (mental
imagery). Monitoring mechanisms refers to the involvement of a number of
processes such as distinguishing between whether an event was internally
generated by the individual or externally presented and perceived by the
individual.
For all types of hallucinations, attention and monitoring (e.g., external
attribution bias) are considered to be of importance. However, in
neurological and pharmacological hallucinations, monitoring errors might
be more a consequence than a cause of the experience of hallucinations,
whereas in psychiatric hallucinations, metacognitive factors may play an
important role in the emergence of the hallucinations. Whereas in
neurological hallucinations, physiological hyperreactivity of sensory and
attentional processes may be the main alterations leading to hallucinatory
experiences, in psychiatric hallucinations, the complex interplay of emotion
and motivation, top-down factors, and monitoring mechanisms may play a
more decisive role.

1
DEFINITION AND CONCEPTUAL
ISSUES
In this chapter, we explore the history of the investigation of
hallucinations and the conceptual issues that have arisen from there. We
then define hallucination and discuss the various definitions used in the
literature.

HISTORICAL DESCRIPTIONS
As was noted by Leudar and Thomas (2000), it is not possible to provide
a continuous history of the phenomenon of hallucination. The information
is simply not available. However, we do know that hallucinations are as old
as humankind. It is curious that the possibility of perception seems to imply
the possibility of misperception. Ancient texts described the phenomenon
of hallucinations, showing that their authors regarded hallucinations as a
culturally integrated aspect of human experience that conveyed a
meaningful message.
Socrates (4th century BC) heard voices and was guided by them in
making decisions. Such hallucinations may not be attributed solely to
sociocultural factors, however, because the experience of a “demon” that
spoke to Socrates was controversial in Athenian culture at that time
(Leudar & Thomas, 2000; Smith, 2007). Thanks to writers and
philosophers such as Plato, Plutarch, and Xenophon, relatively detailed
(although perhaps not entirely objective) accounts of Socrates’ life are
available to us. This is not always the case for other important historical
figures, but although not always documented in sufficient detail, evidence
does suggest that other important historical figures may also have had
hallucinatory experiences, including scientists and philosophers (e.g.,
Galileo, Freud, Jung, Pascal, Pythagoras, Swedenborg) and artists (e.g.,
Schumann, Blake, Munch, Milton, Artaud; see Leudar & Thomas, 2000; D.
B. Smith, 2007; Watkins, 1998). That Joan of Arc was guided by
hallucinations has been well documented (D. B. Smith, 2007; Spence,
2004). We can also read in the literature that Galileo heard the voice of his
dead daughter (Leudar & Thomas, 2000), and Freud (1901/ 1966) himself
wrote,
During the days when I was living alone in a foreign city … I quite often heard my name suddenly
called by an unmistakable and beloved voice; I then noted down the exact moment of the
hallucination and made anxious enquiries of those at home about what had happened at that time, (p.
261)
Of course, in religious experience, be it in the past or in the present,
idiosyncratic perceptions (i.e., an individual perceives something others in
the immediate vicinity do not perceive) abound.
Drug-induced hallucinations have been mentioned in ancient Chinese
texts. The Pěn-ts’ao Ching, the oldest pharmacopoeia known, stated that
the fruits (flowering tops) of hemp, “if taken in excess will produce
hallucinations” (literally “seeing devils”; Li, 1974). The ancient medical
work also stated, “If taken over a long term, it makes one communicate
with spirits and lightens one’s body” (Li, 1974). Not until the 18th century,
however, were hallucinations systematically described as a separate entity
and considered to be “fallacies of the senses” (Dufour, cited in Berrios,
1996) or even as a “disease” (Berrios, 1996). Before the 19th century,
hallucinations were termed apparitions and were generally not seen as
erroneous perceptions but as mystical and spiritual experiences.
In De genesi ad litteram, Augustine (354-430 AD) outlined three types of
apparitions or visions: intellectual, imaginative, and corporeal. An
example of the first type is the experience alluded to by St. Paul as a vision
of the “third heaven.” The second is exemplified in the vision of St. Peter at
Joppa, and the third is exemplified in the vision of Belshazzar in the book of
Daniel. Paul described a vision of the third heaven as follows in his letter to
the Corinthians:
Although there is nothing to be gained, I will go on to visions and revelations from the Lord. I know a
man in Christ who fourteen years ago was caught up to the third heaven. Whether it was in the body
or out of the body I do not know—God knows. And I know that this man—whether in the body or apart
from the body I do not know, but God knows—was caught up to paradise. He heard inexpressible
things, things that man is not permitted to tell. (2 Cor. 12:1-4)
The vision of Peter was described as follows in the book of Acts:
I was in the city of Joppa praying, and in a trance I saw a vision. I saw something like a large sheet
being let down from heaven by its four corners, and it came down to where I was. I looked into it and
saw four-footed animals of the earth, wild beasts, reptiles, and birds of the air. Then I heard a voice
telling me, “Get up, Peter. Kill and eat.” (Acts 11: 5-7)
 The Bible also contains a vivid description of the vision of Belshazzar:
King Belshazzar gave a great banquet for a thousand of his nobles and drank wine with them….
Suddenly the fingers of a human hand appeared and wrote on the plaster of the wall, near the
lampstand in the royal palace. The king watched the hand as it wrote. His face turned pale and he was
so frightened that his knees knocked together and his legs gave way. (Daniel 5:1, 5-6)
According to Augustine, the intellectual vision is an essentially mystic
experience without the presence of a visual object. The object of an
intellectual vision usually concerns higher theological concepts, such as the
Holy Trinity, the essence of the soul, the nature of heaven, and the like. The
imaginative vision, in contrast, is somewhat more concrete than the
intellectual and may accompany mystical experiences but is not limited to
believers. Although it also lacks a visual object, the human imagination is
touched to create a visual representation. Often the visionary is aware that
it is a purely reproduced or composite image that exists only in the
imagination. This kind of vision occurs most frequently during sleep.
The difference between an imaginative and a corporeal vision, according
to Augustine, is that the imaginative vision, although having a visual
component, is not seen by the eyes and leaves no physical evidence of its
effects. The corporeal vision, on the other hand, is registered by the human
eye and at times leaves physical effects. The corporeal vision can either be a
figure really present or a supernatural power that directly modifies the
visual organ and produces in the composite a sensation equivalent to that
which an external object would. The presence of an external figure may be
seen in two ways. Sometimes the very substance of the being or the person
will be present; sometimes it will be merely an appearance consisting of a
certain arrangement of luminous rays. Although Augustine mainly limited
his discussion of apparitions to visual phenomena, mystics in his tradition
also recognized auditory apparitions, usually as an inner voice. This
phenomenon was called locution.

French and German Psychiatry

Although visions and locutions were widely reported earlier, it was not
until the 19th century that more systematic and scientific study was made
of the phenomenon. It was at that time that the concept of hallucination
was introduced, with a major contribution by French psychiatrists, for
example, Jean-Etienne Esquirol in 1832, Alfred Maury in 1855, and Brierre
de Boismont in 1856. Overviews of their conceptual thinking have been
given by Sarbin and Juhasz (1967), Berrios (1996), and Leudar and Thomas
(2000), among others.
The word hallucination has its roots in the Latinhallucinere or allucinere,
meaning “to wander in mind” or “idle talk.” The first usage of the word
hallucination in the English language was in the 1572 translation of a work
by Lewes Lavater, to refer to “ghostes and spirites walking by nyght”
(quoted in Sarbin & Juhasz, 1975). However, it was Esquirol (1817) who
introduced the concept of hallucination, as currently understood, into
psychiatry. Before the 19th century, there was no generic class to include all
hallucinatory experiences (Berrios, 1996). Esquirol proposed
that hallucination be used as the generic name.
Hallucinations of eyesight have been called visions but this term is appropriate only for that sensory
modality. One cannot talk about “auditory visions”, “taste visions”, or “olfactory visions”. The latter
phenomena, however, share with visions the same mechanisms and are seen in the same diseases. A
generic term is needed for all. I propose the word hallucination. (quoted in Berrios, 2005, p. 242)
In his book Mental Maladies: A Treatise on Insanity, Esquirol
(1845/1965) described a person experiencing hallucinations to have a
“thorough conviction of the perception of a sensation, when no external
object, suited to excite this sensation, has impressed the senses.” Shorter
(2005) noted that Esquirol thus used the term in its modern sense of
perceptions without a real external stimulus. That is not to say, however,
that the phenomena of hallucinations as such (without using the
word hallucination) had not been described earlier in psychiatric literature,
as is evident from the writings of William Cullen (who lived from 1710 to
1790), the Scottish systematizer of illnesses, among others (see Shorter,
2005). Esquirol also wrote about possible mechanisms underlying
hallucinations. He started from the assumption that “seeing” is the capture
of a public stimulus, applied this to visions (which only differ in the fact
that no external object is present), and generalized this to other sense
modalities (Berrios, 1996). Furthermore, Esquirol (1832) regarded
hallucinations as arising from neural hyperactivity during memory
retrieval: “The activity of the brain is so energetic that the visionary, the
person hallucinating, ascribes a body and an actuality to images that the
memory recalls without the intervention of the senses.” Lelut, in 1846, and
Tanzi, in 1909 (cited in Berrios, 1996) voiced similar beliefs by suggesting
that hallucinations were transformations of thoughts into sensations, or
ideas stored in memory that go back to perceptual centers and thus become
hallucinations. A number of current cognitive theories can be considered
elaborations of this position (seechap. 4, this volume).
Whereas early French psychiatrists such as Louis François Lelut and
Jules Baillarger considered hallucinations always to be pathological (i.e.,
signs of mental illness), Brierre de Boismont in 1861 maintained that not all
hallucinations should be tied to madness (see Leudar & Thomas, 2000).
Instead, he distinguished
between physiological andpathological hallucinations. Physiological
hallucinations can occur in healthy people: They are compatible with
reason and can be voluntary (as was the case with Goethe, according to
Brierre). Thus, hallucinations of thinkers like Socrates or religious
visionaries like Joan of Arc would be regarded as physiological
hallucinations by Brierre. Pathological hallucinations, on the other hand,
are almost always associated with “delirious conceptions” and “childish
terrors.” This approach is radically different from the medicalization of
hallucinations by other French psychiatrists of the time. Leudar and
Thomas (2000) summarized Brierre’s position as follows: “The madness of
hallucinations was in their involuntariness, delirious content, its falsity,
childish terror of the hallucinator; in other words, nothing specific to
hallucinating” (p. 12). We will see in chapter 3 of this volume that current
researchers distinguish between pathological and nonpathological
hallucinations in a similar way.
According to Berrios (2005), it was the French psychiatrists in the first 30
years of the 19th century who decided that hallucinations were (a) primary
disorders of perception; (b) the same class of phenomena, regardless of the
sense modality in which they occurred; (c) generated by stimulation of
brain regions related to perception and hence mechanical responses with
no semantic or informational import; and (d) medical problems. It could be
added that the focus was not on the content of the hallucinations but rather
on the formal occurrence per se (i.e., that one perceived something that was
not objectively present). The content or meaning of the hallucination was
considered to be of little relevance.
Berrios (2005) noted that the German contribution to the development of
the concept of hallucination has received less attention than the French
one. He drew attention to a German book published in 1826 by Johannes
Müller (1801-1858), Ueber die phantastischen
Gesichtserscheinungen(Fantastic Phenomena of Vision). Berrios argued
that Müller’s book, also written during the first half of the 19th century,
offers insight into the early stage of the process of naturalization of
hallucinations. Apparently, the development of conceptualizing
hallucinations as homogeneous phenomena that form a “natural kind” (i.e.,
analogous to everyday objects around us rather than being abstract entities)
was not an exclusively French pursuit.
Berrios (2005) cited a paper by Brierre that made reference to Müller.
This way of viewing hallucinations profoundly affected the way
hallucinatory experiences were interpreted. Increasingly, mystical visions
and similar experiences were no longer seen as the communication of
supernatural origin. Instead, natural explanations were advanced. Müller,
for example, claimed that visions are “fantastic,” by which he meant that
they are the result of overactivity of a putative faculty of fantasy or
imagination (Berrios, 2005). Others maintained that hallucinations involve
processes similar to dreaming. Brewer (1898/2005) made this point using
examples from literature ranging from Shakespere to Descartes to Sir
Walter Scott.

Medical Versus Psychological Viewpoints

Berrios (1985) and Slade and Bentall (1988) pointed out that from the
very beginning of conceptual thinking about hallucinations, two different
approaches can be distinguished: the psychological and the medical. In
general, the former considers the hallucinatory experience as continuous
with normal experience, whereas the latter regards it as discontinuous with
normal experience. For instance, taking a psychological approach, Hibberts
(1825) considered imaginations and hallucinations (“apparitions”) to be
part of a continuum of completely natural and ordinary mental experiences.
In a similar vein, Sir Francis Galton (1883/1943), one of the pioneers of
scientific psychology, argued that there is a continuity between all forms of
visual imagination, from an almost absence of pictorial thought to images
so vivid that they are indistinguishable from full percepts, thereby ending in
complete hallucination. In contrast, Arnold (1806) and Esquirol (1832)
considered hallucinations to be pathological and categorically distinct from
normal mental events. Thus, there is a discontinuity between hallucination
and normal perception. According to Arnold, hallucinations only arise after
a defect to bodily organs whereby incorrect information is transmitted to
the brain.
Although the medical model has been dominant over the past centuries,
the controversy about pathology versus normality of hallucinations
continues up to the present day. During the second part of the 20th
century, hallucinations were widely regarded to be signs of mental illness
by psychiatrists, presumably due to the strong influence of Schneider’s
(1957) classification of hallucinations as a “first rank” symptom of
schizophrenia. However, large population-based studies have established
that people from the normal population, without psychiatric illnesses,
experience hallucinations (see chap. 2, this volume). A consensus seems to
emerge that pathological and nonpathological forms of hallucination exist,
whereby aspects such as attributions (e.g., of omnipotence of the “voices”),
loudness, frequency, degree of distress that they elicit, and negative and
emotionally threatening content seem to be decisive factors (Chadwick &
Birchwood, 1994; Choong, Hunter, & Woodruff, 2007; Johns & van Os,
2001). Chapters 2 and 3(this volume) further discuss the phenomenology of
hallucinatory experiences and different groups of hallucinators,
respectively.
It is interesting that Freud (1900/1938) regarded hallucinations as
regressions—that is, to thoughts transformed into images. He suggested
that “only such thoughts undergo this transformation as are in intimate
connection with suppressed memories, or with memories which have
remained unconscious” (p. 462). Freud proposed this explanation as the
basis for “the hallucinations of hysteria and paranoia, as well as the visions
of mentally normal persons” (p. 462), suggesting that he recognized a
continuum between hallucinatory experiences in the normal population
and in psychiatric disorders. As noted before, Freud had even experienced
hallucinations himself.

DEFINING HALLUCINATION
In more contemporary accounts of hallucination, it has been difficult to
find an unambiguous definition. Nonetheless, it is important to agree on a
suitable working definition that will guide theory and research, and in
describing efforts at reaching such a definition, we will be able to demarcate
hallucinations from other phenomena that might share some
phenomenological features. The APA Dictionary of Psychology defined
hallucinations as “a false sensory perception that has the compelling sense
of reality despite the absence of an external stimulus” (VandenBos, 2007, p.
427; see Exhibit 1.1 for the complete definition). This certainly captures the
essence of a hallucinatory experience, although a more precise description
should be possible. For example, the statement “despite the absence of an
external stimulus” might not be entirely accurate, because some
hallucinations are triggered by (irrelevant) external stimuli—for example,
patients who start hearing voices when the vacuum cleaner is switched on.
Hallucinations have been defined in different ways (see Exhibit 1.1 for a
list), although they have a number of elements in common.
We favor the definition provided recently by David (2004):
A sensory experience which occurs in the absence of corresponding external stimulation of the
relevant sensory organ, has a sufficient sense of reality to resemble a veridical perception, over which
the subject does not feel s/he has direct and voluntary control, and which occurs in the awake state,
(p. 108)
Veridical perception here refers to the accurate perception of what is real.
This definition by David (2004) is a revision and extension of previous
definitions proposed by Slade and Bentall (1988) and Aleman and de Haan
(1998). Slade and Bentall defined hallucinations as “any percept-like
experience which (a) occurs in the absence of the appropriate stimulus, (b)
has the full force or impact of the corresponding actual (real) perception,
and (c) is not amenable to direct and voluntary control by the experiencer”
(p. 23). The definition demarcates hallucinations from illusions by
indicating that the hallucination arises in the absence of the appropriate
stimulus and emphasizes the sensory quality of hallucinations by specifying
that a hallucination has “the full force or impact of the corresponding actual
(real) perception.” Furthermore, this definition distinguishes hallucinations
from mental imagery by adding that the hallucination “is not amenable to
direct and voluntary control by the experiencer.” After all, mental imagery,
in contrast to hallucination, is generally under the control of the
experiencer (Kosslyn, 1994).
EXHIBIT 1.1
Definitions of Hallucinations

  Hallucination is a false perception characterized by externalization and a

continued belief that the experience is a perception of something outside
the self rather than an internal thought or image. (Campbell, 2004, p. 312)
  A true hallucination will be perceived as being in external space, distinct
from imagined images, outside conscious control, and as possessing
relative permanence. (Oxford Handbook of Psychiatry, Semple, Smyth,
Burns, Darjee, & McIntosh, 2005)
  A false sensory perception that has a compelling sense of reality despite
the absence of an external stimulus. It may affect any of the senses, but
auditory hallucinations and visual hallucinations are most common.
Hallucination is typically a symptom of psychosis, although it may result
from substance abuse or a medical condition, such as epilepsy, brain tumor,
or syphilis. (APA Dictionary of Psychology, VandenBos, 2007, p. 427)
  Hallucinations are images based on immediately internal sources of
information, which are appraised as if they came from immediately
external sources of information. (Horowitz, 1975, p. 165)
  Any percept-like experience which (a) occurs in the absence of the
appropriate stimulus, (b) has the full force or impact of the corresponding
actual (real) perception, and (c) is not amenable to direct and voluntary
control by the experiencer. (Slade & Bentall, 1988, p. 23)
  A sensory experience which occurs in the absence of external stimulation
of the relevant sensory organ, but has the compelling sense of reality of a
true perception, is not amenable to direct and voluntary control by the
experiencer, and occurs in the awake state. (Aleman & de Haan, 1998, p.
657)
  A sensory experience which occurs in the absence of corresponding
external stimulation of the relevant sensory organ, has a sufficient sense of
reality to resemble a veridical perception, over which the subject does not
feel s/he has direct and voluntary control, and which occurs in the awake
state. (David, 2004, p. 108)

Despite its merits, however, this definition runs into a number of

problems. First, the meaning of “percept-like” remains vague. Is mental
imagery also percept-like? In addition, the phrase “in the absence of the
appropriate stimulus” may need specification. Hallucinations can be
triggered in some patients by certain stimuli, such as background noise. In
some patients a sensory stimulus is required in the sensory organ
corresponding to the modality in which the hallucination is occurring (i.e.,
hearing church bells when the telephone is ringing). Here “hearing church
bells” is a hallucination and “the telephone ringing” is the stimulus in the
sensory organ (ear in this case) corresponding to the modality in which
hallucination is occurring. Thus, the hallucination is precipitated by a
specific function of the corresponding sensory organ.
In other cases, the hallucination can be triggered by certain thoughts,
fears, or events. David’s (2004) definition circumvents this by stating that a
hallucination is “a sensory experience which occurs in the absence of
corresponding external stimulation of the relevant sensory organ” (p. 108).
In the second part of their definition, Slade and Bentall (1988) required the
hallucination to have “the full force or impact of the corresponding actual
(real) perception” (p. 23). This might be a rather stringent condition
because some patients may hear soft, mumbling voices or see fleeting
silhouettes on the neighbors’ roof. The phrase proposed by David may
capture the intention of this part of the definition better: “has a sufficient
sense of reality to resemble a veridical perception” (p. 108).
 The final part of Slade and Bentall’s (1988) definition concerns voluntary
control of the experience, when they stated that a hallucination “is not
amenable to direct and voluntary control by the experiencer.” This may
again be too stringent, because a number of patients do have a certain
amount of control. For example, some patients apply coping techniques,
such as turning on the television, to diminish their hallucinations.
Conversely, other patients are able to induce hallucinations by certain
thoughts or actions. The crucial point is that patients generally do not feel
they are in control of the experience. Hence, David’s (2004) revised
definition states that hallucinations are states “over which the subject does
not feel s/he has direct and voluntary control” (p. 108).

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Product Details
 Hardcover: 317 pages
 Publisher: Amer Psychological Assn; 1 edition (February 2008)
 Language: English
 ISBN-10: 1433803119
 ISBN-13: 978-1433803116
 Product Dimensions: 10.1 x 7.3 x 1 inches
 Shipping Weight: 1.4 pounds (View shipping rates and policies)
 Average Customer Review: 4.5 out of 5 stars  See all reviews (2 customer
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Editorial Reviews
About the Author
André Aleman is a Professor of Cognitive Neuropsychiatry at the University Medical Center
Groningen, the Netherlands. He obtained his MSc in neuropsychology and his PhD from the
University of Utrecht. His research foci include the cognitive and neural basis of hallucinations,
emotional processing in schizophrenia and depression and the psychological and neural
underpinnings of poor illness awareness in psychosis.
Frank Larøi works in the Cognitive Psychopathology Unit at the University of Liège, Belgium. He
obtained his BSc from the University of Bath, his cand.psychol degree in clinical psychology from the
University of Oslo, and his PhD from the University of Liège. In addition to hallucinations, his research
interests include schizophrenia, delusions, cognitive remediation, awareness of illness, and emotional
processing in psychopathology.

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Hallucinations brought into focus

By leisure coach on March 3, 2014
Format: Kindle Edition Amazon Verified Purchase
This book brings together a lot of the current information about hallucinations, historical information
through the most up to date brain imaging and chemical interactions. Written with a broad audience in
mind, it refers the reader to more detailed scources while outlining the various approaches to
understanding hallucinations.
I found that while it provided good insight into the proposed mechanisms I would have liked to have
seen a section on interpreting meaning from hallucination.
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1 of 2 people found the following review helpful

Hallucinations: the facts, the science, and the inferences
By W. Sid Vogel on July 10, 2012
Format: Hardcover Amazon Verified Purchase
As a layman, I was interested in the science of visions, hallucinations, and trying to understand the
historical descriptions of hallucinations given modern science. The authors investigate ancient and
historical descriptions of visions and hallucinations, and provide current scientific explanations for this
mental phenomenon. Several descriptions of hallucinations are provided and separate analysis of the
various types of visions. One interesting point is that there is no historical evidence of group
hallucinations. Evidently, what the followers of Jesus experienced after his death was not a
hallucination. This is a good read for the professional and the layman, it is accessible, organized, and
coherent. Well documented and supported this is an excellent text for anyone interested in the subject
of hallucinations.
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