Poe aptly describes the fear and anxiety that so frequently walk hand-in-hand with the process known as psychosis. Amidst this tapestry of fear and anxiety, a plethora of psychological traps are interwoven, including hallucinatory phenomena, oddities of perception, and difficulties in language formation and cognition. In this chapter we will attempt to move, wing by wing, through the matrices of our patients to better understand the destruction that psychotic process causes the people beneath these diagnoses.
As we saw in Chapter 10 where we discovered that depression can cause widespread disruption across a patient’s matrix, psychotic process spreads throughout each and every wing of our patients’ matrices like a virus, wreaking havoc on each wing, from the biological to the familial and the spiritual. The more we understand the nuances of this destruction and its movement, the more likely we will be able to develop interviewing techniques and strategies that can help our patients to share their pain with us; this is the goal of this chapter. We will also discover that psychotic process can impact on the interview process itself.
Our abilities to navigate these hurdles and to sensitively spot the subtle emergence of psychotic process is one of the most pivotal and sophisticated skills that any mental health professional can bring to the table. It is a skill that can help us to begin the healing process, whether one is a college counselor sitting with a student experiencing a first break of schizophrenia, a social worker functioning as a crisis worker in an emergency room encountering a patient with a drug-induced psychosis, or a psychiatrist working with a patient admitted to an inpatient unit with command hallucinations to kill himself.
The Pain Beneath Psychotic Process
Fields of Interaction
I The Biological Wing of the Matrix
Sleep Disturbances in Psychosis
One of the major physiologic moorings of our daily lives is the routine appearance of the phenomenon known as sleep. If one’s sleep patterns are disturbed, one quickly begins to feel “not quite oneself.” It appears as no surprise then that a sleep disturbance often appears early in the psychotic process.
As psychotic process begins to gain momentum, the patient often experiences severe problems falling asleep. In some instances the patient will eventually undergo a day/night reversal, in which sleep occurs during the daylight hours and the night becomes a time of agitation. The patient may also experience other sleep disturbances, such as early morning awakening, especially if the psychosis is part of a major depression.
This difficulty with falling asleep stands as a sensitive sign of impending psychosis, frequently appearing during periods of delusional mood or delusional perception. The patient sometimes denies this sleep disturbance. Consequently, it is useful to ask family members about the patient’s sleep, because they have frequently been awake themselves, coping with the growing restlessness of their family member.
Psychotic Disruption of the “Sensation of the Physical Boundaries of the Body” and the Concept of a “Porous Ego”
Leaving the area of sleep disruption, one is confronted with another set of somatic concerns created by psychotic process, and these concerns are far removed from normal experiences like sleep: Psychotic patients frequently have problems with determining the limits of their bodies, and in a parallel sense, the limits of their sense of self, their “realness,” or sense of “mineness,” so to speak.
It has been suggested that patients experiencing psychotic process often regress to an infantile state in which the body is viewed as part self and part object.1 At such points, the person may experience such intense feelings of depersonalization or derealization that they actually move past these phenomena into odd psychotic experiences in which the patient loses the sense of self or autonomy of self. One such type of experience is known as a “made volitional act,” vividly described by one patient as follows:
I look at my arms and they aren’t mine. They move without my direction. Somebody else moves them: All my limbs and my thoughts are attached to strings and these strings are pulled by others. I know not who I am. I have no control. I don’t live in me. The outside and I are all the same.2
When intense, such feelings may be associated with a terrifying sense of impending annihilation. Perhaps, this blurring of inner and outer reality is the almost otherworldly fear that Roderick Usher felt was his destiny in Poe’s story. It is important to realize the intensity of these fears, because they provide insight into the sometimes violent and drastic measures of psychotic patients.
The above quotation leads us into a more sophisticated exploration of psychotic disruptions in the boundaries of the ego. In essence, one can view psychotic patients as possessing a “porous ego.” The world seems to invade their skins in a distinctly unpleasant fashion. They experience a variety of sensations, which seem to enter from the outside world while becoming one with them. It is this unidirectional invasion of their integrity that is partially responsible for their fear and anxiety.3 It is this feeling of invasion, and the dissolution of the integrity of the body, that characterizes many of what have come to be known as Schneiderian symptoms.
Schneiderian First-Rank Symptoms of Psychosis
Kurt Schneider, one of the 20th century’s leading European psychiatric innovators, was a pupil of the great phenomenologist Karl Jaspers. Schneider descriptively captured the weird sensations of these invasion experiences. He mistakenly thought that the presence of any of these symptoms, if not caused by another medical condition, almost guaranteed the presence of schizophrenia. He consequently called these symptoms “first-rank symptoms” of schizophrenia (often referred to as FRS in the clinical literature). The notion of these symptoms as near confirmation of the presence of schizophrenia proved to be incorrect, for these symptoms can be seen fairly frequently with other diagnoses in which there is psychotic process. But Schneider’s symptoms are an excellent inventory of common psychotic phenomena, whatever their etiology, and questions concerning them should be part of any interviewer’s repertoire. There is considerable evidence that they are, indeed, more common in schizophrenia than in other causes of psychosis such as mood disorders or in psychotic disorders caused by a medical condition.
Schneider described 11 symptoms, of which seven are characterized by feelings of invasion by the outside world. These seven symptoms are: (1) somatic passivity experiences, (2) made feelings, (3) made impulses, (4) made volitional acts, (5) thought withdrawal, (6) thought insertion, and (7) thought broadcasting. The remaining four Schneiderian symptoms are delusional perception (a symptom we discussed in great detail in the previous chapter) and several types of auditory hallucinations – audible thoughts, voices arguing, and voices commenting upon one’s actions.
The literature on Schneiderian FRS can be confusing, for Schneider, to some degree, did not clearly define them in his own writings, resulting in various interpretations being given by subsequent writers.4,5 To me, the symptoms are best understood by remembering that Schneider was greatly influenced by the philosophy and psychology of phenomenology. Phenomenologists are primarily interested in understanding the fashion in which human beings experience being in the world, including the individual’s unique concerns as to how their experiences are related to their sense of self and to others. In a general sense, phenomenologists are less interested in secondarily categorizing experiences as specific “things” such as delusions or hallucinations than in trying to understand, as best they can, how a unique human being has experienced a unique phenomenon within his or her mind. Let me clarify this somewhat-confusing abstraction with a specific Schneiderian symptom – thought withdrawal.
A patient can experience thought withdrawal in different ways. A patient may literally feel a thought being withdrawn from his or her brain/skull as a perception (a haptic hallucination) or a patient could cognitively believe that his or her thoughts are being withdrawn, without necessarily feeling it as a sensation (a delusion, without any precipitating hallucination). Both of these are experienced by patients as real inner phenomena or truths. I believe that for Schneider, it was this inner experience of thought withdrawal that was most important, not whether the patient’s experience could be subsequently classified as a hallucination versus a delusion.
Likewise, a patient could interpret this inner phenomenon in various fashions. The patient could, in a nebulous way, simply feel as if a nonspecific, non-identified outside agent had done the withdrawing (a feeling state not a delusion); or the patient might vaguely believe that an outside entity had withdrawn the thought (an over-valued idea); alternatively, he or she could definitely believe that an outside agent had withdrawn the thought (a true delusion); further yet, he or she could arrive at a specific belief as to who (a neighbor) or what (a demon) had withdrawn the thought (an elaboration and refinement of the patient’s delusion).
In my opinion, Schneider, as a phenomenologist, was most likely interested in all of these aspects, viewing them as integral parts of the patient’s inner experience. It was not that the person had either a hallucination and/or a delusion that would matter most to a classic phenomenologist. It was the fact that a person had experienced the phenomenon of thought withdrawal and had been concerned about it (in whatever unique fashion it was experienced and in whatever unique fashion the patient had experienced the concern) that raised Schneider’s suspicion that the patient was experiencing a psychotic world.
It is also important to understand that Schneider did not believe that the mere presence of one of these symptoms indicated the existence of psychotic process or even psychopathology. The symptom had to be embedded within a psychotic matrix, as we described in our previous chapter. He warned, “a psychotic phenomenon is not like a defective stone in an otherwise perfect mosaic.”6 The need to examine the specific symptom within the overall context of the patient’s experience Schneider described as the requirement for the presence of “phenomenological leverage.” This leverage (psychotic matrix) had to be present in order to determine that a symptom was truly psychotic in nature.7 With these clarifications in mind, let’s take a closer look at Schneider’s first-rank symptoms.
Exploring Somatic Passivity and “Made Feelings”: The World of the Porous Ego
Schneider did a marvelous job of capturing the essence of these psychotic sensations, which, traditionally, clinicians have a hard time uncovering because they are so foreign to normal experience. A clinician can empathize with paranoia to some extent, because we have all experienced fear of other people to some degree or another. But “somatic passivity” and “made feelings” are something altogether different. They are psychologically foreign phenomena to most clinicians, hence are easily missed. Moreover, despite the damaging power of these symptoms (and the consequent value of targeting them for relief via supportive reassurance, cognitive–behavioral therapy, or medications, etc.), many patients – because the symptoms sound so “crazy” to others in the patient’s everyday culture – will not share them unless directly asked about them by the interviewer.
With somatic passivity experiences, the patient is the reluctant recipient of bodily sensations against his will by a force outside of his control such as suddenly feeling that his intestines are wriggling about inside his abdomen or that his organs are shifting about. It is easy to see how such peculiar sensations could plant the seeds of delusional material such as a paranoid fear that someone is purposely twisting the patient’s insides or that parasites or snakes have infested his intestines. The following type of question can help to bring such sensations to light:
Similarly, in made feelings, made impulses, and made volitional acts, the patient once again feels that something is “being done to them.” Personal control is taken from the patient (sometimes referred to in the literature as delusions of control). This distinct and remarkably unnerving feeling that “I am being made to feel something, made to want to do something, or actually being made to do a specific act against my will” (such as assaulting or killing someone), is the unifying perception of all three of Schneider’s “made” symptoms. It is a poignant example of a “porous ego,” made vulnerable to invasion at any moment by psychotic process. Mellor, in a classic article on Schneiderian FRS, quotes a patient who describes the oddness of a “made feeling”:
I cry, tears roll down my cheeks and I look unhappy, but inside I have a cold anger because they are using me in this way, and it is not me who is unhappy, but they are projecting unhappiness into my brain.8
Another of Mellor’s patients insightfully describes the sensation of “made volitional acts” of which we already saw one example above. In this instance, the patient is describing that his fingers pick up objects but, “I don’t control them … I sit there watching them move, and they are quite independent, what they do has nothing to do with me. I am just a puppet … I am just a puppet who is manipulated by cosmic strings.”9
Notice how it would be natural for any person experiencing these “made sensations” or somatic passivity experiences to wonder who or what is causing them. This drive to figure out, “what is happening to me?” is totally normal. Unfortunately, as the patient seeks out an answer, they will inevitably come upon an unrealistic answer for the original sensation is psychotic in nature. Their resulting explanation for the made feeling or somatic passivity experience – a demon is making me feel hate or parasites have invaded my intestines – is a delusion. Thus we see that delusions are often the result of a person’s natural hunt for answers to an unnatural, psychotic experience. This sequential understanding complements what we saw in the last chapter when we described the “life cycle of a delusion” and the concept that the presence of delusions is evidence of an old psychosis.
Armed with an understanding of this life cycle of a delusion, an interviewer may be better able to spot the emergence of subtle psychotic process. This could result in lower anti-psychotic dosages, and perhaps a much less virulent episode of psychosis, for the patient. For instance, a talented interviewer may uncover an insidiously emerging first break of schizophrenia or the earliest signs of a break-through in a patient’s psychotic process (previously well-controlled by medications) despite the fact that the patient is denying the presence of delusions. The clinician can accomplish this task by utilizing questions that are designed to uncover the type of made symptoms or somatic passivity experiences that often pre-date delusional thoughts.
The following questions can be of value in uncovering these unsettling sensations, all of which can lead to the development of delusional material:
“Have you ever felt that something or someone is making you feel an emotion, as if something is making you feel angry, sad, or bitter?” (uncovers made feelings)
“Does it sometimes feel like something or someone is giving you urges that you would never want to do normally, like the urge to yell out at a stranger, use a profanity, or even hurt someone physically?” (uncovers made impulses)
“Right before you assaulted your boss, and I know you feel very badly about that now, what were you feeling, right before you hit him? (an open-ended indirect method of potentially uncovering made volitional acts)
“Have you ever felt that something or someone made you actually assault your boss?” (a closed-ended direct method of uncovering made volitional acts)
Thought Withdrawal and Thought Insertion
Two other Schneiderian symptoms – thought withdrawal and thought insertion – are reflections of a porous ego. Both sensations are extraordinarily unsettling.
Once again, the operative words are “to me,” in that the patient feels that these phenomena are being done “to me” by some outside force. In normal day-to-day functioning, all of us have the discrete sensation that we exist and that we do things to the world about us and even to ourselves. It is a distinct sensation of intentionality. This sensation of intentionality is so innate that people are generally unaware of it. It simply is. But with all of the Schneiderian symptoms discussed thus far, the patient feels that there is some external, disembodied force that is capable of causing them to feel and do things, creating a penultimate fear of loss of control.
So it is with thought withdrawal and thought insertion. In the former, the patients feel, become suspicious, or believe that their thoughts are literally being pulled out of their minds by an alien force. If not present immediately, paranoid delusions are usually quick to follow, as the patient tries to understand or explain the etiology of his or her sensations. Inwardly the patient may feel that his or her mind has had a thought removed, sometimes even in mid-sentence. In an interview, this inward experience may show itself outwardly. The patient may demonstrate thought blocking, in which a sentence is disrupted before completion and the patient cannot recover his or her train of thought. Thought withdrawal can be addressed as follows:
“Have you ever felt that some person or perhaps something like a demon or perhaps the web can pull or remove your thoughts from you, you know, against your will?”
In contrast, with thought insertion, the patient feels or believes that thoughts from a different entity are being forced or pushed into his or her mind. The phenomenon is a truly weird experience, often accompanied by over-valued ideas or delusions frequently tied into demon possession or other types of paranoid delusions, such as a computer or smart phone pushing thoughts into the patient’s mind. I have found the following questions to be of use in exploring these sensations:
“You mentioned that your neighbor, Ben, is trying to control you. Does he try to do things like control your thoughts or even literally push his own thoughts into your mind?”
“Does it ever feel to you that you can literally feel Satan pushing these feelings into your mind, against your will?”
“Have you ever felt that thoughts are being pushed into your mind through your smart phone that aren’t your own?”
Thought Broadcasting (Unintentional and Intentional)
Unfortunately, the patient’s porous ego may also allow for the passive escape of thoughts, feelings, and desires. The result may be fears that aggressive fantasies will be heard by others in the room or, even worse, that in a magical sense, these violent ideas may automatically become reality. A common feeling is that the patient’s thoughts are leaking, as elegantly described below:
My difficulty is an outgo of my silent thought. It goes as it comes. I may think whatever I please, but whatever I do think goes as it comes. I suppose the constant irritation and annoyance they have kept up around me has affected the tension of nerve, so that unlike others who have the same phenomenal power, it goes as rapidly as my mind thinks. I have but to think a thought and it reaches other minds in sound without an effort on my part, and is sounded for a distance, I suppose, of 2 or 3 miles.10
This type of passive thought broadcasting is sometimes called “thought diffusion.” I find the term “thought leakage” more descriptive of the fear attached to the phenomenon by the people experiencing it. One can imagine the intense concern accompanying such a phenomenon, for suddenly there is no privacy whatsoever. What one thinks, others can hear. Generally, thought leaking is experienced in very negative terms. Patients may even feel that their thoughts are being beamed out on radio or television, or simultaneously magically posted on Facebook or other social media.
Note that thought broadcasting is a decidedly different sensation to thought withdrawal. The locus of the experience is not that something is being actively done to oneself (an agent is pulling my thoughts out), but that one’s thoughts are leaking outwards through a porous ego.
In some rarer instances of thought broadcasting, it feels to patients that they are capable of intentionally sending thoughts from their minds. In such instances, the thought broadcasting may be viewed in a pleasurable light – as a special ability or skill. The following questions can be used to uncover both types of thought broadcasting (unintentional leakage or an intentional sending of thoughts):
“Jim, are you ever worried that other people can read or hear your thoughts without your awareness, or perhaps your inner thoughts are somehow posted on the web without your knowing it?”
“Sometimes people have told me that they have been lucky enough to develop some unusual or special powers, like ESP. For instance, some people have told me that they have the ability to send their thoughts outward into the minds of others, sometimes great distances. Have you ever experienced anything like that, even just a little bit?”
One can quickly sense the inherent strangeness of a world encountered with a porous ego. One can more easily intuit why these patients frequently seem preoccupied or lost in thought. It requires tremendous attention to try to sort out the meanings of so odd and intrusive a world. The clinician must also bear in mind that these patients are frequently attempting to determine which of their sensations are real and which are false. To the degree that they possess a “distance” from their psychosis, they will realize that much is unreal. As the psychosis deepens, this distance is lost, and the inexplicable becomes a reality that needs no explanations.
Spotting Medication-Induced Akathisia
Thus far, the focus has been on the somatic sensations and physiologic ramifications of psychotic process. However, with the advent of antipsychotic medications, which have remarkably enhanced our ability to decrease psychotic process, a new set of problems has unfortunately appeared. Antipsychotics can negatively impact on the extrapyramidal structures of the brain known as the basal ganglia (areas such as the globus pallidus and putamen) that lie deep within the brain beneath the cortex; they are important brain centers, regulating movement and many other activities.
Patients may develop significant movement-related side effects, especially with traditional antipsychotics such as Haldol and Prolixin, when the physiology of these brain structures is adversely effected. These side effects are less common with newer atypical antipsychotics such as Risperdol, Clozaril, and Seroquel, but certainly can still be seen with these medications, sometimes quite severely. We already discussed one of these extrapyramidal side effects in which the patient’s affect becomes blunted or flat (no expression) secondary to an antipsychotic-induced Parkinson’s syndrome. We saw that this blunting could be easily mistaken by an interviewer for the blunted affect so characteristic of schizophrenia.
A second side effect, akathisia, can also confuse the initial interviewer, because it can be mistaken for evidence of psychotic agitation. Akathisia is most commonly caused by both typical and atypical antipsychotics, but it can also be triggered by other medications including selective serotonin reuptake inhibitor (SSRI) antidepressants, as well as two antiemetics. Akathisia represents a symptom in which patients feel that a part or all of their body needs to move. It is a deep-seated feeling of restlessness. Generally it will show itself as the physical sign of moving about in an agitated fashion, sometimes with a smallish, prance-like step.
It is important to remember that akathisia is a subjective symptom, not a physical sign. In this sense the patient may not always appear agitated or be pacing. Instead, the person may only experience the unpleasant sensation of feeling intensely restless. By way of illustration, if in addition to akathisia the patient has also developed the stiff-like Parkinson’s syndrome described above, the patient may move very little, despite an intense drive to move. Needless to say, this type of paradoxical situation creates an extremely discordant sensation for the patient.
It is easy to mistake akathisia for psychotic agitation; consequently the interviewer must be alert for it. When severe, akathisia represents a new and bizarre sensation that a patient already having problems with psychotic process certainly could do without. Some authors have reported incidents in which they felt that akathisia either worsened a psychotic state or, at times, predisposed the patient to inflict self-damage, including suicide.
In the following direct transcription, a young professional describes his experiences with akathisia. At the time of the transcript he was no longer psychotic. When the medication had been utilized, he had been suffering from a frightening delusional system. He had also been told about akathisia and its transitory nature, but his psychotic process appears to have disrupted this information. I have never heard akathisia or its interplay with psychotic process so eloquently described:
Pt.: I was very aware of a different kind of feeling from what I usually have. It felt as if it was most immediately recognizable in the morning, in that I felt that I just couldn’t go through with my normal morning routine, like taking a shower and shaving and everything I do to get ready for work. It felt more like I couldn’t do it because I couldn’t stand to wait that long, to go through those things which were such routine motion.
Clin.: Like, what are some of things that were routine?
Pt.: Well, like standing under the shower. It just seemed impossible to stand under the shower for any much longer and once I got done with the shower it seemed impossible to stand there and dry myself.
Clin.: Okay. What do you mean when you say it wasn’t possible. What was it that you felt would happen if you did stay there?
Pt.: That I would break out of my skin or something like that. But, uh, that I would be so upset and unsettled that I would just be totally destroyed I think. It’s just very unsettling.
Clin.: Now, did the experience change over time? In other words, were there parts of the day where you would feel worse than other parts?
Pt.: It was pretty much general all day. When I got to work, I have a sit-down job. I do remember that it was hard to stay put. It was really hard to sit. I do a lot of reading in my job and it was very hard to concentrate on the things I have to read, and as a consequence it made me feel ineffectual in my work. I just felt totally wiped out at work. I felt like I really couldn’t keep working if I were to keep having this feeling.
Clin.: You mentioned the ineffectual feeling. Did you start to feel upset about being ineffectual?
Pt.: Oh, sure. Yeah, I felt that I was going to be a failure, really, if I were to keep feeling this way. I thought it would become evident right away to all the people around me that I was really screwing this up and that I really couldn’t do my job anymore. And, in fact, I even got a little panicky about that.
Pt.: Yeah, I just felt like being between a rock and a hard place because the feeling was that I had to sit there and keep doing my work because I was at work. On the other hand, my body felt like I just couldn’t keep doing that anymore, and, uh, it was like you were in a crisis every second is what it was really like. Between wanting to stay there and do your job and being unable to do so.
Clin.: Did you have any fears that somehow or other that this state would not go away? You know, that this was going to continue?
Pt.: Definitely. I had the fear that the drug had set off something in my system whereby, even if I stopped the drug, that I was going to continue to have this feeling. What was definitely very much a part of the feeling was the fact that how could I go through the rest of my life feeling this way? That was very much a part of it.
Clin.: Now, what types of things did this sort of lead you to think then, that you couldn’t do your work and that this state might not change?
Pt.: Uhmm, I felt depressed about it, and, uh, it led me to feel scared and afraid that something was going to happen.
Clin.: Do you think that you got more frightened or nervous than you had been before? In other words, did the unpleasant sensation increase your own anxiety just because you were having it?
Pt.: Oh, yes. Definitely. I was very anxious being around other people, that they might perceive that I was in this agitated state.
Clin.: Did you have any feelings that you should try to hurt yourself or that you might hurt yourself? … because of the …
Pt.: Yes, it did seem, it did occur to me that it would be easier not to live than to live this way. That probably seems really heavy, but that did occur to me. I did, I had a resurgence of suicidal thoughts during those feelings.
Clin.: What kinds of things were you thinking at the time?
Pt.: Uh, usually blowing my head off. Really, I was thinking about that and just ending it all because it just, I think every drug I ever took, I always had the fear that it would do something, … that it would never go away again.
One aspect that can help the interviewer attempt to sort out akathisia from psychotic agitation is the fact that akathisia represents a true bodily sensation. Patients will generally describe a need to move, an actual restlessness within the limbs. This is not generally the case when the agitation is caused by psychotic process. If the patient lacks other psychotic symptoms that could be triggering intense anxiety, then it is also more likely that akathisia is the main problem. But at times the only way to distinguish akathisia from psychotic agitation is to attempt to treat one or the other process. Fortunately with the patient described above, the akathisia was greatly relieved by lowering the dose of the antipsychotic.
Interviewing patients who are experiencing extrapyramidal side effects is often a daily experience for mental health professionals across disciplines, especially if one works in a community mental health center, an inpatient unit, or an emergency room. Let us now turn our attention to a puzzling syndrome that a clinician is a great deal less likely to see on a frequent basis, but is nevertheless important to understand. Indeed, it is its relative rarity that makes it important that we review interviewing techniques that can help us to reach these patients when we do encounter it.
Establishing an Alliance With a Patient Experiencing Catatonia
In the 1800s, catatonia was a relatively frequently seen syndrome, especially if one was walking the back wards of “insane asylums.” It is much less frequently encountered by the clinicians of today. Nevertheless, it is encountered. When it is, contemporary clinicians must be prepared to help patients suffering from it. Skilled interviewing may be the first step towards breaking the psychological chains that bind these patients so tightly to a world beyond human interaction.
Psychotic process can disrupt the normal control of activity levels to an extreme degree, resulting in aberrant patient behavior ranging from agitated catatonia, in which the patient cannot stop moving, to stuporous catatonia, in which the patient shows little movement at all. It is to this peculiar state of stuporous catatonia that we shall turn our attention.
At one time, catatonia was generally believed to be primarily associated with schizophrenia. More recently, it has been viewed as a symptom complex that is not only seen in schizophrenia but also in mood disorders, hysterical dissociation, and in a variety of medical illnesses including autoimmune encephalitides triggered by infectious agents and cancers.11
Stuporous catatonia is often associated with mutism, lack of movement, negativism (as shown by a tendency to not comply with any requests), and ambitendency. This latter trait reveals itself as a hesitancy to complete behaviors, demonstrated by actions such as extending one’s hand to shake and then removing it. All of these behaviors have been referred to as the “negative symptoms of catatonia” (not to be confused with the negative symptoms of schizophrenia, described in the previous chapter).
Stuporous catatonia is also associated with the so-called positive symptoms of catatonia (once again not to be confused with the positive symptoms of schizophrenia), such as the holding of bizarre postures, the senseless repetition of the clinician’s words, and waxy flexibility. This latter phenomenon manifests itself as a bizarre willingness to hold one’s body in any position to which it is moved.
The initial interviewer is faced with the question of how to approach a catatonic patient. It is not clear exactly what such patients are experiencing, and most likely the experience varies from one patient to another. Apparently some patients seem well aware of what is going on around them whereas others may be lost in peculiar feelings of timelessness and autism.
When speaking with a patient experiencing catatonia, gentleness is imperative. It can seem second nature to talk more loudly if someone is not responding to your questions. Remain gentle in tone, calm in pace of your speech. Always keep in mind that the patient may be processing your words quite effectively, either consciously or unconsciously. One simply does not know. Consequently, speak normally and be sure to say whatever you want to communicate, for the patient may not acknowledge what you are saying on the spot, but he or she may be silently processing it in the moment or later that day. A simple comment such as, “It’s okay not to talk now, but any time you feel like talking, please do so. And feel free to ask any of the staff if I’m around. I’ll try to talk with you as soon as I am available. It would be a nice thing to do.”
A logical question arises as to whether one should attempt a nonverbal technique such as touching the patient. Generally speaking, I believe that in an initial interview the answer is no, primarily because one simply does not know what these patients are experiencing. If delusional or actively hallucinating, the patient may perceive the clinician as attacking. Moreover, some of these patients can move almost immediately from stillness into hyperactive states.
I am reminded of one such patient who I inadvisedly touched. She was lying on the floor in an unresponsive state. We were concerned about the possibility of an overdose. When she did not respond to loud questions, I shook her shoulders. To my shock she immediately grabbed me and attempted to bite me. Apparently, drugs were not the issue.
However, in certain unusual instances the clinician may decide that it would be useful to touch a catatonic patient. If such a decision is reached, then some simple principles should be followed. In the first place, someone else should be in the room, and safety officers should be aware that the patient may be unpredictable. The patient should be told in a calm and reassuring voice exactly who the clinician is and what the clinician is about to do. Patients should also be told why they are being touched and that if at any point they want to be left alone they should simply say so. The clinician should be prepared to quickly take evasive action.
I am reminded of a woman in her mid-30s, suffering from schizophrenia. During the interview she sat with her head wrenched straight back while wincing with apparent pain. For about 10 minutes she refused to answer any questions. Her neck continued to hyperextend, as her face further contorted in pain. A second clinician stepped in at this point and said the following, “Ms. Jackson, I am one of the physicians here. I can see that you are in some kind of pain. I am concerned that you may be having a type of drug side effect (dystonic response to her antipsychotic), and I would like to see if I can help relieve your pain. In a moment you will feel me touching the back of your head. I will be trying to see if I can get your neck to move more freely. If you want me to stop, just tell me.” The clinician proceeded to do just as he said, while continuously informing the patient as to his next move. In about a minute, the patient’s neck straightened, allowing the interview to continue, although she went on to speak in a disorganized fashion. Her neck spasm was hysterical, not medication related.
II The Psychological Wing of the Matrix
Auditory Hallucinations: Their Nature, Phenomenology, and Exploration
Auditory hallucinations are false perceptions of sounds, both human and non-human. They represent one of the trademarks of psychotic process. To the layperson, the presence of “voices” is practically synonymous with madness. To the clinician, auditory hallucinations are one of the true hard signs of psychosis, although, as we have already seen, they can be experienced by people without psychopathology.
As described by Waters in an excellent overview of auditory hallucinations, the most common type of hallucination in psychiatric disorders is a voice.12 These voices may be of people known to the patient, unknown to the patient, reality based (as with a family member, political leader, or celebrity), or imagined (as with a god, a demon, or an angel). The voices are commonly single words, but often contain complete sentences or questions and, at times, are quite complex, including multiple voices conversing (often commenting on the patient’s behavior) as well as voices with which the patient engages in an ongoing conversation.
Hallucinations may also be nonverbal, composed of grunting sounds, machine noises, unrecognizable sounds, and music.13 One of my patients, a college student suffering from a psychotic bipolar disorder, told me that about 30 minutes before he would descend into his most harrowing psychotic periods (characterized by vicious demonic voices), he would often hear, very distinctly, the pleasant music of an ice-cream truck. He related he could hear the truck approaching and leaving, and the music was indistinguishable from the real thing.
He would later discover that he could creatively use this phenomenon as an early warning sign of an acute psychotic worsening. As soon as he heard the ice-cream truck, he took a prn (i.e., as needed) dose of his antipsychotic medication often effectively short-circuiting the demonic voices. Quite remarkable and quite resourceful! It highlights that each person must determine how to interact with his or her unique hallucinatory processes. In this case the patient used one type of pleasurable hallucination – the music of an ice-cream truck – to help him prevent the occurrence of a disturbing type of hallucination – demonic voices.
Auditory hallucinations are commonly seen in psychiatric disorders. It has been reported that 75% of patients with schizophrenia and between 20 to 50% of patients with bipolar disorder experience auditory hallucinations. Many clinicians think of auditory hallucinations in association with these two disorders, but it is important to realize that they can appear with many other disorders. Approximately 10% of patients with major depressive disorder experience auditory hallucinations and prevalence rates of up to 40% have been reported for patients with post-traumatic stress disorder, generally experienced during intense flashbacks.14
Determining whether a patient is having hallucinations, whether abnormal or normal, is not as easy as one might think, because, for the most part, the clinician must depend upon the patient’s self-report. As we have seen, errors in validity appear more frequently when one must depend upon patient opinion as opposed to the elucidation of behavioral incidents. Because of this, it may be best to start with a basic question regarding the nature of auditory hallucinations, such as “Are they heard inside your head or outside of your head?” The answer may come as a bit of a surprise.
The Directional Location of Auditory Hallucinations
For quite some time, clinicians tended to clump reports of auditory hallucinations into two categories: pseudohallucinations and true hallucinations. This distinction may well have found its most fertile roots in the writings of Karl Jaspers, whose work we encountered before in Chapter 10. Jaspers seemed to believe that there was no continuum between hearing one’s thoughts and hearing true hallucinations. Patients either had hallucinations or they did not. With true hallucinations he felt that two elements were always present. First, the hallucination was substantial in the sense that it seemed real and had many of the sensory qualities of a real perception. Second, the hallucination seemed to occupy space. With an auditory hallucination, this suggests that the voice came from a given area outside the head.
But Jaspers was incorrect, as Fish and others have pointed out, and modern clinical experience has borne out.15–17 There does appear to be a continuum, and I have talked with many patients with schizophrenia who describe their voices as “being in my head.” In some instances, as the psychotic process progresses, these voices move out into space and truly seem more real at that point. In other cases, the voices seem to be originating either from inside or outside the patient’s head, often appearing to be quite real in either circumstance. But the bottom line remains that auditory hallucinations can be experienced in both ways. And the DSM-5 accepts both voices from inside and outside the head as representing hallucinatory phenomena.
The concept of the apparent localizability of a hallucination might be better viewed with regard to whether a voice is heard within the mind (which has no location) or outside the mind (where a location can be assigned). With some patients, the voice is heard only within the mind. In contrast, with many hallucinations the voice can be physically located, and this location may even be reported as being inside the patient’s head as with “A radio transmitter is broadcasting from inside my head, where my neighbor implanted it.” The internal terrain of the body can actually represent a geographic space and a source of hallucinatory phenomena in this regard. With other patients, the voice is heard as coming through the ear, on the surface of the body, or anywhere in external space.18
Copolov and colleagues reviewed the literature devoted to the location of auditory hallucinations and performed a study on these phenomena. They found that 34.5% of their patients reported hearing the voices inside their heads, 27.9% outside their heads, and 37.6% both inside and outside; these proportions were similar to the previous studies they reviewed.19 There appeared to be little clinical significance – in terms of severity of symptoms and the patient distress – when comparing where the patients perceived their voices originating.
There was evidence that patients who heard their voices internally tended to exhibit better reality testing and distance from their psychotic process than patients who heard their voices externally. Counter-intuitively, however, patients who heard command hallucinations only externally, reported being able to resist the commands more effectively than patients who heard them only internally or both internally and externally. We will discuss the significance and techniques for exploring command hallucinations shortly.
On a diagnostic note, it is important to be on the lookout for the relatively rare disorder of dissociative identity disorder (DID; previously known as multiple personality disorder). In this disorder, patients may internally hear the voices of their alters. Keep in mind that if a patient reports hearing voices internally, it is unlikely that he or she has dissociative identity disorder. It is much more likely that the patient has schizophrenia or some other psychotic disorder. Note that in DID the voices will generally not be imbedded in a psychotic matrix as described in Chapter 11. Thus in DID one does not tend to see elements such as delusional mood, delusional perception, and other phenomena suggestive of a budding psychotic process, a useful point for discriminating between the voices of DID and the voices seen in psychotic disorders such as schizophrenia.
The Reality of Auditory Hallucinations to the Patient
Auditory hallucinations are viewed as veridical perceptual phenomena, a term that simply means that patients frequently are convinced of the veracity or realness of the hallucinations. On the other hand, each patient is a unique individual and their distance (insight) from these hallucinatory phenomena can vary. In an interview it is useful to explore what a patient means if he or she comments that his or her voices sound real. Such patients, upon more detailed interviewing, may tell the clinician that the voices are quite real but do not sound exactly like normal voices. It is not uncommon for psychotic patients to be able to identify their hallucinations as abnormal. Sometimes they may even have names for them.
If a clinician is attempting to decide whether or not a patient is faking hallucinations, these points become important. A patient who is malingering may tend to describe the voices as sounding exactly like normal voices, which remains possible in psychosis but is not typical. The malingerer may also describe the voices as happening all of a sudden, unaware that hard psychotic symptoms usually have subtle prodromal phases such as delusional mood and delusional perception. Moreover, the voices found in processes such as schizophrenia are frequently hostile in nature and often hurl nasty and/or obscene insults at the patient.
The following type of question can be useful in recognizing malingered hallucinations:
Distinction Between Auditory Hallucinations and Auditory Illusions
The difference between auditory hallucinations and auditory illusions is the same as the difference between visual hallucinations and visual illusions; this latter we discussed in Chapter 11. An auditory hallucination occurs without any auditory stimulus, whereas an auditory illusion is a distortion of an actual sound. Thus, an example of an auditory illusion would be a paranoid patient hearing the words, “I hate you. I’m going to slit your throat” when his friend actually said, “I’d never be late for you. I’m going to be exactly where I told you I’d be before.” Obviously, an auditory illusion can be as frightening or as dangerous as an actual auditory hallucination.
Another distinction should be made. There is an odd phenomenon known as a functional auditory hallucination. In this process, an external sound triggers, sometimes fairly consistently, an actual auditory hallucination. Both the triggering sound and the auditory hallucination are heard quite clearly without any distortion.20 For instance, the sound of a phone ringing triggers a hallucination of a neighbor’s voice denigrating the patient from the next apartment. Both the sound of the phone ringing and the sound of the neighbor’s voice are distinct and heard clearly without distorting one another. Thus, in a functional hallucination, the extraneous environmental sound merely functions as a trigger for the auditory hallucination.
The Uniqueness of Auditory Hallucinations
From the perspective of person-centered interviewing, it is critical to understand that hallucinations, although they may share various characteristics among patients as we have been describing, are, ultimately, phenomenologically unique to each person experiencing them. In a wonderful paper, Stephane and colleagues21 have described the phenomenological structure of auditory verbal hallucinations.
They found that voices vary along 20 phenomena and continua. For instance, voices differ in their acoustic qualities from clear (like external speech) to deep (like internal speech or thinking in words). Other acoustic qualities included the personification (male, female, robot) and loudness. Another variable is of the time course of the hallucinatory process (constant versus episodic). The linguistics of the voices can clearly vary as in the syntax (first person, second person, or third person) and the complexity of the communication (hearing words versus sentences versus conversations). Yet another prominent feature was what Stephane called the “affective relatedness,” a rather fancy name for whether the voices were comforting or pleasurable versus frightening or bothersome. Considering that Stephane and colleagues found over 15 other characteristics, one can see that voices can present with remarkable variation from person to person. Table 12.1 summarizes Stephanes’s phenomenological categories.
Table 12.1
Phenomenological Forms of Auditory Verbal Hallucinations.
| FORMS | DIMENSIONS | CHARACTERISTICS |
| Acoustic qualities | Clarity | Clear (like external speech) vs. deep (like internal speech/thinking in words) |
| Personification | Man’s voice, woman’s voice, or other agent (alien, robot, etc.) | |
| Loudness | Softer vs. louder vs. similar to normal conversational volume | |
| Location | Inner space | In the head, or other parts of the body |
| Outer space | ||
| Number of voices | One, more than one | |
| Direction | Voices talk among themselves | |
| Voices talk to the patient | ||
| Linguistic | Syntax | First (I) vs. second (you, name) vs. third person (he/she, name) |
| Complexity | Hearing words vs. hearing sentences vs. hearing conversations | |
| Content | Range | Repetitive vs. systematized |
| Focus | Self vs. non-self | |
| Order | First order (hear voices) | |
| Second order (talk back to the voices) | ||
| Third order (converse with the voices) | ||
| Replay | Experiential (heard in real life) | |
| Arising from patient’s speech | ||
| Arising from patient’s thoughts | ||
| Source attribution | Self | |
| Other | Someone familiar, God/spiritual being, or deceased person | |
| Time course | Time dimension | Constant vs. episodic |
| Modulation | Worsening vs. improving | |
| Mode of occurrence | Spontaneous | |
| Triggered | By intentional will or by other triggers | |
| Happens when | Speaking or listening to speech | |
| Listening to non-speech sounds | ||
| Doing activities requiring attention | ||
| Control strategies | Listening to speech or speaking | |
| Listening to non-speech sounds | ||
| Doing activities requiring attention | ||
| Affective relatedness | Comforting | |
| Bothersome/intrusive |
Schneiderian Symptoms Related to Auditory Hallucinations
Kurt Schneider provides further insight into the qualities that may impact on how a particular patient experiences his or her voices. As you will recall, three of Schneider’s 11 first-rank symptoms concern voices. One of these symptoms consists of the patient experiencing audible thoughts. In this phenomenon, the patient hears his or her thoughts just after having the thought, almost like an internal echo. Alternatively, the patient may hear an undecipherable voice, the content of the speech only becoming clear a few seconds after hearing it. The other two Schneiderian symptoms consist of arguing voices and multiple voices commenting on the patient’s activities, patterns of hallucinatory dialogue that are not uncommon in schizophrenia.
The Relationship Between the Patient and the Patient’s Voices
It is not only the clinician that has many questions to ask regarding voices. Each patient experiencing voices is seeking answers to a plethora of pressing questions relating to his or her personal relationship to the voices themselves. To the patient, each voice has its own demands and supposed expectations, much like a family member or friend. Patients are frequently searching for answers to the following types of questions: (1) Is this voice real or unreal? (2) Who or what is creating it? (3) Does it mean me harm or good? (4) Will it go away when I want it to go away or am I stuck with it? (5) Do other people hear it? (6) Can it read my thoughts? (7) Does it want me to do something? (8) Must I do what it wants?
Waters elegantly describes how the answers to such questions coalesce to create a powerful relationship for the patient, a relationship that can match or exceed the importance of relationships with actual family members, friends, or society at large:
The content of voices is usually highly personalized. The voices frequently express what the person is feeling or thinking and speak about his or her fears or worries. Psychiatric patients view the content of voices to be meaningful and to have personal relevance. The voices are interpreted to be the manifestation of real people or entities, and this experience contributes to the intense emotional response to the voices. The personalized content and subjective reality of voices play a role in the development of strong beliefs about the intent and power of the voices, and a complicated and intense relationship frequently ensues between patients and their voices.22
Patients search for answers to their questions about the nature of their voices upon their very first “contact” with them. The following excerpt lucidly presents the eerie world created by such a first meeting:
Seated on a steamer chair on the boardwalk of Coney Island, I heard the voice for the first time. It was as positive and persistent as any voice I had ever heard. It said slowly, “Jayson, you are worthless. You’ve never been useful, and you’ve never been any good.” I shook my head unbelievingly, trying to drive out the sound of the words, and as if I had heard nothing, continued to talk with my neighbor. Suddenly, clearer, deeper, and even louder than before, the deep voice came at me again, right in my ear this time, and getting me tight and shivery inside. “Larry Jayson, I told you before you weren’t any good. Why are you sitting here making believe you’re as good as anyone else when you’re not? Whom are you fooling? You’re no good,” the voice said slowly in the same deep tones. “You’ve never been any good or use on earth. There is the ocean. You might as well drown yourself. Just walk in and keep walking.” As soon as the voice was through, I knew, by its cold command, I had to obey it.23
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