Sacks - Hallucinations

THIS IS A BORZOI BOOK
PUBLISHED BY ALFRED A. KNOPF AND
ALFRED A. KNOPF CANADA

Copyright 2012 by Oliver Sacks, M.D.

All rights reserved. Published in the United States by Alfred A. Knopf, a division of Random House, Inc., New York, and in Canada by Alfred A. Knopf Canada, a division of Random House of Canada Limited, Toronto.

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Library of Congress Cataloging-in-Publication Data Sacks, Oliver W.
Hallucinations / Oliver Sacks. 1st American ed.
p.; cm.
Includes bibliographical references.
I. Title.

[ DNLM : 1. Hallucinations. 2. Perceptual Disorders. WM 204]
616.89dc23 2012002877

Library and Archives Canada Cataloguing in Publication Sacks, Oliver W.
Hallucinations / Oliver Sacks.
eISBN: 978-0-307-95725-2
1. Hallucinations and illusions. 2. Perceptual disorders. I. Title.
RC553.H3S23 2012 616.89 C2012-902091-5

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For Kate

W hen the word hallucination first came into use, in the early sixteenth century, it denoted only a wandering mind. It was not until the 1830s that Jean-tienne Esquirol, a French psychiatrist, gave the term its present meaningprior to that, what we now call hallucinations were referred to simply as apparitions. Precise definitions of the word hallucination still vary considerably, chiefly because it is not always easy to discern where the boundary lies between hallucination, misperception, and illusion. But generally, hallucinations are defined as percepts arising in the absence of any external realityseeing things or hearing things that are not there.

Perceptions are, to some extent, shareableyou and I can agree that there is a tree; but if I say, I see a tree there, and you see nothing of the sort, you will regard my tree as a hallucination, something concocted by my brain or mind, and imperceptible to you or anyone else. To the hallucinator, though, hallucinations seem very real; they can mimic perception in every respect, starting with the way they are projected into the external world.

Hallucinations tend to be startling. This is sometimes because of their contenta gigantic spider in the middle of the room or tiny people six inches tallbut, more fundamentally, it is because there is no consensual validation; no one else sees what you see, and you realize with a shock that the giant spider or the tiny people must be in your head.

When you conjure up ordinary imagesof a rectangle, or a friends face, or the Eiffel Towerthe images stay in your head. They are not projected into external space like a hallucination, and they lack the detailed quality of a percept or a hallucination. You actively create such voluntary images and can revise them as you please. In contrast, you are passive and helpless in the face of hallucinations: they happen to you, autonomouslythey appear and disappear when they please, not when you please.

There is another mode of hallucination, sometimes called pseudo-hallucination, in which hallucinations are not projected into external space but are seen, so to speak, on the inside of ones eyelidssuch hallucinations typically occur in near-sleep states, with closed eyes. But these inner hallucinations have all the other hallmarks of hallucinations: they are involuntary, uncontrollable, and may have preternatural color and detail or bizarre forms and transformations, quite unlike normal visual imagery.

Hallucinations may overlap with misperceptions or illusions. If, looking at someones face, I see only half a face, this is a misperception. The distinction becomes less clear with more complex situations. If I look at someone standing in front of me and see not a single figure but five identical figures in a row, is this polyopia a misperception or a hallucination? If I see someone cross the room from left to right, then see them crossing the room in precisely the same way again and again, is this sort of repetition (a palinopsia) a perceptual aberration, a hallucination, or both? We tend to speak of such things as misperceptions or illusions if there is something there to begin witha human figure, for examplewhereas hallucinations are conjured out of thin air. But many of my patients experience outright hallucinations, illusions, and complex misperceptions, and sometimes the line between these is difficult to draw.

T hough the phenomena of hallucination are probably as old as the human brain, our understanding of them has greatly increased over the last few decades. This new knowledge comes especially from our ability to image the brain and to monitor its electrical and metabolic activities while people are hallucinating. Such techniques, coupled with implanted-electrode studies (in patients with intractable epilepsy who need surgery), have allowed us to define which parts of the brain are responsible for different sorts of hallucinations. For instance, an area in the right inferotemporal cortex normally involved in the perception of faces, if abnormally activated, may cause people to hallucinate faces. There is a corresponding area on the other side of the brain normally employed in readingthe visual word form area in the fusiform gyrus; if this is abnormally stimulated, it may give rise to hallucinations of letters or pseudowords.

Hallucinations are positive phenomena, as opposed to the negative symptoms, the deficits or losses caused by accident or disease, which neurology is classically based on. The phenomenology of hallucinations often points to the brain structures and mechanisms involved and can therefore, potentially, provide more direct insight into the workings of the brain.

H allucinations have always had an important place in our mental lives and in our culture. Indeed, one must wonder to what extent hallucinatory experiences have given rise to our art, folklore, and even religion. Do the geometric patterns seen in migraine and other conditions prefigure the motifs of Aboriginal art? Did Lilliputian hallucinations (which are not uncommon) give rise to the elves, imps, leprechauns, and fairies in our folklore? Do the terrifying hallucinations of the night-mare, being ridden and suffocated by a malign presence, play a part in generating our concepts of demons and witches or malignant aliens? Do ecstatic seizures, such as Dostoevsky had, play a part in generating our sense of the divine? Do out-of-body experiences allow the feeling that one can be disembodied? Does the substancelessness of hallucinations encourage a belief in ghosts and spirits? Why has every culture known to us sought and found hallucinogenic drugs and used them, first and foremost, for sacramental purposes?

This is not a new thoughtin 1845, Alexandre Brierre de Boismont, in the first systematic medical book on the subject, explored such ideas in a chapter titled Hallucinations in Relation to Psychology, History, Morality, and Religion. Anthropologists including Weston La Barre and Richard Evans Schultes, among others, have documented the role of hallucinations in Time has only broadened and deepened our appreciation of the great cultural importance of what might at first seem to be little more than a neurological quirk.