You must always be puzzled by mental illness
The thing I would dread most,
if I became mentally ill,
would be your adopting a common sense attitude
that you could take it for granted
that I was deluded

Ludwig Wittgenstein

When I reflect on Wittgenstein's quote, I imagine that he was trying to point out that mental illnesses are imbued with meanings, they are not glitches in a 'broken brain.' As Shakespeare would also point out, there is a method in madness. When it comes to auditory hallucinations, one could write them off as evidence of a functional disconnectivity syndrome (between prefrontal and temporal regions) or a self-monitoring defect in which an internally generated thought ('voices') or action (passivity phenomena in schizophrenia) is incorrectly attributed to an external source (e.g., the research of Chris Frith and colleagues in London). I remember being at an NIH conference many years ago, in which Thomas McGlashan and Roy Hoffman attempted to demonstrate through computer models that you can have output without input (a model of auditory hallucinations-as parasitic attractors-in the language of complexity theory). As a psychologist-psychotherapist working in an inpatient psychiatric unit in the south Bronx at the time, I raised the issue of the dynamic meanings of the 'voices.' I noted that many of my patients seemed to be suffering from various traumatic events in their development and that their 'voices' seemed to be reflective of this. The issue was not responded to by the presenters. After decades of studying this phenomenon, with my own clinical material and in the various research domains, I wrote a paper, "Confusion of Identities and the Auditory Hallucination: Phenomenology, Neurobiology, Cognitive and Psychoanalytic Models of Understanding and Therapy," which I presented in Stavanger, Norway at our ISPS conference. I have since discovered research evidence which may very well reflect upon this phenomena as meaningful and reflective of personal developmental experiences.

In my updated paper, “Auditory Hallucinations: Speaking One’s Dissociated Mind,” I report on the research of Hubl and Dierks (2004), using fMRI with hallucinating individuals with a diagnosis of schizophrenia. Specifically, they were interested in studying the activation order of key neural regions mediating this symptom. This is an important aspect of research because temporal order of neural activation can potentially throw some much-needed light on the dynamic nature of hallucinations. The dynamic nature of schizophrenic symptoms, from a neuroimaging perspective has been noted by Honey et al (2003), “Imaging brain structure and function in schizophrenia: new techniques encounter old problems” in “Neuroimaging in Psychiatry” edited by Fu et al (2003): “....interregional functional connectivity is, to a large extent, dependent upon synaptic changes that occur in response to experience-abnormalities in these changes are likely to produce abnormal connections” (p. 242). Psychoanalytically, Arieti suggested that prior to the actual experience of hearing a voice, the patient, in a certain affective state, e.g., loneliness or intense anxiety, places himself in a ‘listening attitude,’ in which she/he expects to hear the voice.

Hubl and Dierks (2004), in brief, discovered the following temporal neural activation pattern: hippocampus, Broca’s area (speech activation), amygdala, PAC (primary auditory cortex-Heschl’s gyrus), and lastly, the primary motor cortex. These investigators concluded: “We interpreted this sequence of pathological activation in the following way: memories come up [I would say emotional memories, possibly traumatic in origin - mediated by the hippocampus], nearly simultaneously the motor speech area [Broca’s area] is activated. This seems to be related to an erroneous functional connection between subjective memories and language system [I would understand this as purposive intentional activity designed to communicate anxiety and emotional pain to an other or Other, a primary, homeostatic, affect-regulating symbiotic maternal presence and/or possibly what some researchers in PTSD have called “speechless terror]”. Broca’s area is a motor speech area and thus is relevant for the generation of inner speech, one mechanism considered to be important for the generation of auditory hallucinations. Somewhat later, the activation of the amygdala contributes to the emotional coloration of the auditory hallucinations [fear, rage, etc], and the activation of the PAC makes this mixture of memory, inner speech and emotional content heard [it is the activation of the PAC which results in the inner voice being perceived as an external ‘real’ voice].

My interpretations of the above data, are that the patient is co-opting intact neural regions to help her/him cope with such issues of past trauma (physical, sexual, emotional abuse as well as emotional neglect), mortifying and humiliating experiences of powerlessness, worthlessness, etc; social exclusion; threats of attachment disruption in terms of abandonment and rejection; separation terror (thus the voice which provides evidence and resonance that one is still alive, is being held in someone’s mind, even if in the mind of a persecutor-which is similar to Fairbairn’s comment that a bad object is better than no object, or reflects on the needed object as persecutory because it contains projected elements of the subject, and/or it is persecutory because it is needed and beyond the omnipotent control of the subject, etc). The identity-maintaining aspects of voices, even if a negative identity, may be similar to Freud’s view of psychotic symptoms (e.g., hallucinations and delusions) as restitutional, i.e., a tie to the object world after the pathogenic withdrawal of emotional investment in the external world of relationships (thought to have originally occurred because of narcissistic injuries). From my clinical observations in long-term psychotherapeutic work with patients who hallucinate, I believe that the voices are the patient’s attempt to speak her/his dissociated mind and are also very much akin to what psychobiologically oriented attachment researchers have called the “separation cry.” The hope in the latter is that a safe attachment figure will locate the separated one, not a predator.

Brian Koehler PhD
New York University
80 East 11th Street #339
New York NY 10003
212.533.5687
brian_koehler@psychoanalysis.net