The Misattribution of the Misattribution Theory: An Analysis of the Cognitive Models of Hallucinations, Part I

Introduction

           

Although rare, visual hallucinations (VH) constitute a well-recognized and rather distressing occurrence to presenting clients. The Diagnostic and Statistical Manual of Mental Disorders, 5^th edition (DSM-5) defines hallucinations as “perception like experiences that occur without an external stimulus” (American Psychiatric Association, 2013).

            The literature on VH is surprisingly vast. Although typically considered the hallmark of schizophrenia spectrum, VH occur across various other pathologies, including—but not limited to—Creutzfeldt-Jakob disease, especially the Heidenhain variant (Brar & Scicutella, 2005), Parkinson’s Disease (Lees, 2005), Charles Bonnet Syndrome (Rovner, 2006), Alzheimer’s disease and dementia with Lewy bodies (Ferman et al., 2013), substance abuse (Nichols, 2004), and even sleep and sensory deprivation (Vernon, 1958).

            A significant portion of the literature of VH is dedicated to understanding the etiology, primarily as a means for prediction and treatment. Asaad and Shapiro (1986) provide a comprehensive review of relevant theories, and categorize them into the following divisions: 1) psycho-physiologic, implying a disruption of brain structures, 2) psycho-biochemical, implicating disturbance of neurotransmitters, and 3) psychodynamic, arguing for the emergence of the unconscious into consciousness. While neurological models of the mechanism of psychotic hallucinations have produced fertile research, this paper will follow Bentall (2007) in arguing that the inclusion of a cognitive heuristic in conjunction with a neurobiological approach will allow for a broader range of research avenues.

            There is a substantial and growing amount of literature describing the genesis of VH (and AHHhh) from a cognitive perspective. In this model, the fundamental hypothesis is that individuals with hallucinations are unable to differentiate between their own private, internal events and external, observable reality (Heilbrun, 1980). Thus, the misattribution of inner speech to an external source would be the source for auditory hallucinations, whereas vivid mental imagery would be the basis for visual hallucinations. Accordingly, in this model, a significant component is the cognitional operation of judgment, whereby an individual confirms or denies the veracity of an object by “testing reality”. Reality testing refers to the ability to differentiate between internal events and external reality (Garret & Silva, 2003). Structured under the umbrella of metacognition, this ability is often referenced as reality monitoring or reality discrimination in less recent literature (Bentall, 1990). In sum, while there is a growing consensus on the plausibility of the misattribution theory, the investigation of the precise cognitive mechanism of action continues.

            Further, there is growing empirical evidence in support of the continuum theory of hallucinations. Briefly, the continuum model claims that 1) psychotic symptoms such as hallucinations may be present in a percentage of the general population, and 2) that both the general population and psychotic populations share common cognitive mechanisms for hallucinatory experiences. For example, in an attempt to further understand the cognitive processes underlying the misattribution error and the role of reality testing, Perky (1910) found that normal subjects were equally susceptible as hallucinators to mistaking a real event for an imagined one. Again, the groundbreaking study by Barber and Calverly (1964) also highlights this phenomenon in normal populations. In this study, after subjects were instructed that they would hear a record of “White Christmas”, they reported hearing the record clearly, although no music was ever played. Finally, more recent research indicates that normal individuals often mistake self-generated memories for memories of the actual events (Johnson & Raye, 1981).  This research seems to confirm the notion that misattributions are not limited to psychotic individuals, but affects normal individuals as well.

            Clearly, then, the ability to distinguish reality from imagination is neither innate nor infallible, and the precise cognitive processes underlying the testing of reality still remain largely unknown. That is, it is assumed that the large majority of people can indeed differentiate between what is real and what is not and the aim of current cognitive research attempts to elucidate the exact mechanisms of this differentiation.

            To be clear, the issue of making correct judgments about the nature of reality is essentially an epistemological issue, and two related but distinct points follow. First, the science of psychology has historically had difficulty forming a unified consensus on such fundamental issues as a theory of knowledge (Martin & Sugarman, 1999). Although academic disagreement can often be the catalyst for new discoveries, lack of agreement on an issue as central as epistemology and the nature of reality leads less often to new insights than to inconsistencies in the literature. Although well beyond the scope of this paper, it can be argued that the epistemological question is of such central importance that it touches on the scientific nature of psychology itself (Staats, 1983; Kantor, 1979). Indeed, this lack of a secure and unified epistemology as foundation for psychological investigation echoes Thomas Kuhn’s (1996) argument that any science holding competing paradigms is only a pre-science until a uniform methodology is adopted.

            Second, although this paper began as a modest inquiry into VH in psychosis, an investigation of the literature revealed a glaringly absent discussion of an epistemological framework governing the research. What the research does reveal, however, is the underlying assumption that human beings create mental images as a fundamental component of knowledge. That is, the mental image (or the inner word in the modality of auditory hallucinations) is misattributed for a real image. This mental representation of sense objects, what some philosophers term ‘abstraction’ or a ‘phantasm’, (Lonergan, 1967b) is foundational for the present research on source-memory deficits and attribution errors. Unfortunately, however, specification of the theoretical framework was entirely absent. Within the realm of common sense, and the pragmatism of everyday life, one’s philosophical position—whether it be the extreme objectivity of a naïve (or critical) realism or the subjectivity of a phenomenological or Kantian idealism—is largely unimportant. In a scientific investigation of the cognitive processes underpinning the misattributions that lead to hallucinations, however, philosophical and epistemological grounding of a theoretical model is essential.

            The following review takes as its starting point this lack of epistemological clarity and uniformity. Reviewing the literature from this theoretical lens, I argue that it is precisely this lack of consensus and explication of a theory of knowledge that has led to inconsistencies within the literature. Analysis of the epistemological underpinnings of the following articles will be offered, and recommendations for future research, based on this paradigm, will be presented. 

By Phillip J. Kuna, PhD (abd)
for John G. Kuna, Psy.D. and Associates Counseling

www.drjohngkuna.com

www.drjohngkuna.com