The Central Nervous System: Correlates of Dreams and Waking Hallucinations

In a previous entry, I explored the connection between the visual system and visual hallucinations reported by individuals with schizophrenia. Since dreams can be understood as the nervous system’s processing of endogenous information, I was interested to understand and explore the correlation between dreams and hallucinations as they are processed by the nervous system.

            Research revealed a fruitful article by Mahowald, Woods, and Schenck titled, “Sleeping Dreams, Waking Hallucinations, and the Central Nervous System.” The authors note that the study concerns the critical evaluation of “the similarities and differences between dreams and hallucinations, with particular reference to the role of the central nervous system in each and with consideration of their patho-physiologic implications.” More of a review of the literature  than an empirical study, the article had 6 major headings: 1) dream mechanisms, 2) hallucination mechanisms, 3) dreaming and hallucinations: state disassociation models, 4) hallucinations (spontaneous and induced) in the non-psychiatric population, 5) dreams and hallucinations as a manifestation of consciousness, 6) hallucinations in neurological disorders.  For the astute reader, a copious and valuable four pages of references follows the article.

            The first section was standard enough. Their presentation of hallucinatory mechanisms stressed a view of endogenous brain activity being released when the individual is dissociated from stimuli: for instance, West’s theory argues that we are always in a dream state; we just are not attending to it because we are constantly stimulated—we can’t see the stars during the day, though they are still there.

            Section 4, while interesting, wasn’t my main interest in the article, as it presented topics such: fasting and sleep deprivation induced hallucinations (especially in religious/mystics), and drug induced hallucinations. Skipping ahead, the final section (6) provided more substance to several related areas, including: hallucinations in Parkinson’s and Alzheimer’s disease, phantom limb syndrome, and Charles Bonnet Syndrome.

            Finally, the fifth section (dreams and hallucinations as a manifestation of consciousness) had interesting correlates to schizophrenic hallucinations. We know that the brain is active during both REM and non REM sleep. Further, we can define consciousness as the brains awareness of all available data presented to it. While awake, this information is our environment, external stimuli. While asleep, however, this stimulus is internally generated. Further, we know from neuroimaging that during REM sleep there is a decrease in PVC (primary visual cortex) and Frontal Association activity. From this information, the researchers hypothesize that “the extrastriate cortices and paralimbic areas may be operating as a closed system, functionally disconnected from the primary visual and the frontal regions responsible for the integration of visual information.”

            Further evidence for this hypothesis that consciousness is maintained by the brain’s spatial and temporal mapping that integrates multiple brain areas can be seen in the fact that both during REM and the wake state there is a 40 Hz oscillatory rhythm throughout the cortex. Such a rhythmic oscillation may provide a continuous “neuronal humming” whereby internal or external irregularities would be conspicuous. What is most interesting is that this rhythm is reset during the wake state by sensory stimuli…but it is not reset during REM sleep.

            The theory, then, is that some deviation of either the spatial or temporal regularity of this rhythm may be at the root of some hallucinations—specifically those experienced by individuals with schizophrenia. Much of the literature uncovered, however, focused squarely on the differences between dreams and hallucinations. The convergence of these themes proved fertile, and we can most certainly anticipate further research involving this intersection. More so as our neurobiological techniques and understanding increases. For instance, it was only 40 years ago that the REM phasic event intrusion hypothesis was offered as an explanation for waking hallucinations in schizophrenia, but this theory was never verified because the prevailing assumption at the time was that dreaming was confined to REM sleep only!

References

Mahowald, M. W., Woods, S. R., & Schenck, C. H. (1998). Sleeping dreams, waking

hallucinations, and the central nervous system. Dreaming, 8(2), 89-102.

doi:10.1023/B:DREM.0000005899.59224.17

by +Phillip J. Kuna

for John G. Kuna, Psy.D. and Associates

drjohngkuna.com

The Misattribution of Misattribution: Analysis of the Cognitive models of Hallucinations, Part IV [Conclusion]

A further study provides an integrative account of several previously discussed constructs.  Again using the misattribution theory as their springboard, Larøi, Linden and Marczewski (2004) explored the relationship between meta-cognitive beliefs, cognitive effort and emotional pertinence on a reality monitoring test of hallucination prone participants. This study is notable for its attempt, not simply to confirm the already well documented misattribution theory, but rather to explain the underlying cognitive mechanism of this process. This study is based primarily on the earlier theoretical work of Morrison, Haddock and Tarrier (1995), who argue that an affect laden cognitive dissonance occurs when an unwanted and intrusive thought contradicts a particular meta-cognitive belief system. This in turn triggers an aversive state of arousal and anxiety. Either unable or unwilling to existentially face this cognitive dissonance, the individual attributes the intrusive thought to an external source (i.e., the event becomes hallucinatory). One example of a meta-cognitive framework ripe for this phenomenon may be, “Not being able to control my thoughts is a sign of weakness” (Larøi, 2007). Finally, the researchers note cautiously that even if such cognitive stars do indeed align they should be seen within the larger context of predisposing factors to hallucinations.

            The researchers tested this hypothesis by first screening 100 undergraduates on the Launay-Slade Hallucinations Scale (LSHS). Those scoring in the upper 25^th percentile were considered hallucination prone (HP; N = 25) and those on the lower 25^th percentile were considered non-hallucination prone (NHP; N = 25). There was no significant distribution difference between genders. A French translation of the Meta-Cognitive Questionnaire (MCQ) was administered to assess participant’s meta-cognitive beliefs systems. Based on a 4-point Likert scale, the 64 question MCQ purports to assesses internal positive and negative beliefs regarding intrusive thoughts and meta-cognitive monitoring based on the following five sub-scales: 1) Positive beliefs about worry (PB), 2) Negative beliefs about the uncontrollability of thoughts and corresponding danger (UD), 3) Cognitive confidence (CC), 4) Negative beliefs about thoughts in general (specifically thoughts related to superstition, punishment and responsibility; SPR), and 5) Cognitive self-consciousness (CSC).

            Participants were then given a reality monitoring test. Similar to other such procedures, the participants were orally presented with 30 words (10 positive, 10 negative, and 10 neutral), and were asked to speak the first word that came to mind. The affect laden words were chosen based in part on the previous work of Braun, Marczewski and Van der Linden (2000). Examples include “bankrupt, suicide, cancer” for negative words, and “paradise, seduce and succeed” as positive words. Neutral words included, “pencil, domain, sheet.” Subjects could provide any verbal response except a proper noun. After a 20 minute delay, participants were shown a computer screen with the original word list, their verbal responses, and distractor words and asked to identify whether the words were from the previous list or not. If the word was from the previous list, participants were instructed to indicate the source—whether participant response or experimenter.

            As predicted, the results indicated a significant difference between the HP group and the NHP group in terms of source discrimination errors, particularly when the material was self-generated (U = 43, p < .05). Again, a significant difference was found between the HP group and the NHP group on MCQ scores. Specifically, the researchers found positive correlations between LSHS scores and all five MCQ sub-scales. Also, interestingly, positive correlations between scores on the UD sub-scale (negative beliefs about uncontrollable thoughts; Spearman r = .49, p < .05), the CC sub-scale (cognitive confidence; Spearman r = .45, p < .05) and source discrimination errors were found. Results were interpreted to support the misattribution theory, as well providing further support for the previously mentioned continuum model of hallucinations.

            While commendable for the testing of multiple constructs relating to hallucinations in normal populations and thus validating previous research, this study’s largest deficit is its inability to explain the cognitive processes involved. As I have argued, this is related to the lack of a systematic account of cognitional operations with which to validate. The implications of this critique are described more fully in the following conclusion.

            Finally, a brief but pertinent study considers the source of hallucinations in individuals with remitted schizophrenia from an information-processing deficit perspective. Miller and Saccuzzo (1979) employed a backward-masking paradigm to assess the initial stages of information-processing in individuals with schizophrenia in remission. In general, visual masking happens when one visual stimulus obstructs discernibility of another visual stimulus. Backward masking, then, is the experimental procedure whereby the target stimulus is presented first, before the masking stimulus (Skottun and Skoyles, 2009). Although somewhat dated, the Miller and Saccuzzo (1979) study is an important contribution to the study of hallucinations in schizophrenic individuals. Additional research has suggested that individuals with schizophrenia have a particular deficiency in the magno-cellular level of the visual system (Green, Nuechterlein, & Mintz, 1994), and abnormal backward visual masking is interpreted as evidence of this claim (Butler & Javitt, 2005).

            Participants included a mere 10 individuals in the normal control group, and an equally sparse 10 individuals with schizophrenia. The schizophrenic individuals, all on anti-psychotic medication, were residents at a care facility with over one year of hospitalization, and three months symptom-free prior to testing. Before testing, participant’s vision was assessed by means of the Snellen Eyey Chart, and language comprehension was measured by the Wechsler Vocabulary subscale.

            In terms of the procedure of backward masking, the researchers employed both a blank masking condition as well a pattern mask by means of a tachistoscope. Each masking condition was affixed to the tachistoscope so that the stimulus was located centrally in the field of vision. The pattern mask was two capital “W’s” adjacent to each other as well as a small, back-lit cross just above the Ws. As Miller and Saccuzzo report, “The fixation field remained constantly illuminated (1.0 ftL or 3.43 cd/m2) providing a lighted background between trials. Luminance in both the stimulus and masking fields was set at 16.33 ftL (55.95 cd/m2) throughout the experiment” (Miller and Saccuzzo, 1979, p. 447). Participants were to detect either a “T” or an “A” from a two-alternative forced choice task. Finally, each masking task was administered under five stages: a no mask control, and subsequent 10, 75, 150, and 250 millisecond delay of the mask to the stimulus presentation. 

            Results indicated that the normal control group made significantly more correct decisions on both masking conditions (p < .01). Similarly, the normal control group scored significantly higher than schizophrenic individuals on both the 2 millisecond delay (p < .01) and the 4 millisecond (p < .05) delay trials. Clearly, individuals with schizophrenia, even though they were non-symptomatic for three months, had more difficulty with detection in the presence of the masking stimulus. These results were interpreted to implicate the possible role pre-cortical processing deficiency. Miller and Saccuzzo argue that, while their conclusions are still tentative, this may be a possible means of measurement of clinical symptomology as well.

Conclusion

            In addition to the over-arching epistemological problem, several specific directions for future research have already been noted throughout this paper: the inclusion of emotionally charged stimuli in experimentation, further investigation into the mediating factors of hallucinations—particularly trauma—as well further examination of the role of cognitive effort and meta-cognitive beliefs.  

Although the hypothesis that misattributed vivid mental images were the origins of VH was proposed by Galton over than 100 years ago (Galton, 1883), a review of the literature reveals that attempts to verify and replicate this claim have been either contradictory or have failed to specify the cognitive mechanism of action. I have argued that the cause for this lack of scientific progress is due to a combination of a fundamental disagreement as well a definite absence of explicit theory of knowledge guiding such cognitive research.

            In the above discussion of the Aleman et al. article, I noted a possible underlying position of positivism. Positivism has arguably been the prevailing philosophical paradigm since inception of modern psychology (Breen and Darlaston-Jones, 2010), since it provides support for psychology as a justified scientific endeavor that is observable, replicable and objective. Recent research into the nature of human consciousness further exemplifies the still current prevalence of positivism. Chalmers (1996), for instance, argues that while attempts to explain the invisible are all well and good, what is physical is ultimately real. Ironically, even researchers in the hard sciences that psychology strives to emulate—say, physics for instance—understand that the particles they investigate are often times simply constructs of human intelligence. Such constructs, while not ultimately tangible, are ways to explain what must indeed be so if they are to offer an explanation of what has actually been observed. In other words, as the history of psychology has shown, despite its limited and initial benefits, the narrowness of positivism is not rich enough to account for the complexities of the human condition, and the future of the science of psychology may be contingent upon the integration of both the objective and subjective components inherent in human cognition.

            Although again constrained by the scope of this paper, future research would do well in looking to the seminal work of the philosopher Bernard Lonergan for a unifying epistemological foundation. Lonergan, by grounding objectivity within one’s own subjectivity and rational self-consciousness, provides a plausible, reliable and indeed first person empirical alternative to the varied epistemological and methodological approaches currently present in psychological theory (Brannick, 2006). With a unified epistemological framework in place, future research would be able to advance by constructing more specialized experiments consistent with such integrated theory of knowledge.  

            In conclusion, this was a cursory treatment of a vast and growing body of literature, and should not be considered a comprehensive review. A complete analysis would entail more detailed comparisons between the theoretical and epistemological underpinnings, especially in instances of conflicting results. Based on this preliminary research, however, I hypothesize that crux of the inconsistencies in the literature are based on a pervasive positivism that mistakenly equates knowledge to ocular vision. That is, as was seen in the Aleman et al. article, the assumption is that internal data are subjective, private events that cannot be understood since they cannot be observed. The difficulty with this position, however,  is that if knowing is simply a matter of taking a good look, then knowing knowing (i.e., meta-cognition) would be nothing more than looking at looking (cf. Lonergan, 1967a). As such, future research would do well to investigate, explicate and unify these often subtle epistemological claims underpinning psychological theory and research.

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Allen, P.P., Johns, L.C., Fu, C.H.Y., Broome, M.R., Vythelingum, G.N., & McGuire, P. (2004).   Misattribution of external speech in patients with hallucinations and delusions.Schizophrenia Research, 69, 277-87.

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Barber, T., & Calverlry, D. (1964). An Experminetal study of ‘hypnotic’ (auditory and visual).     The Journal of Abnormal and Social Psychology, 68(1), 13-20. doi:10.1037/h0042175.

Bentall, R., Fernvhough, C., Morrison, A.P., Lewis, S., & Cocoran, R. (2007). Prospects for a     cognitive developmental account of psychotic experiences. British Journal Of Clinical  Psychology, 46 (2), 155-173. doi:10.1348/014466506X123011

Bentall, R.P. (1990). The illusion of reality: a review and integration of psychological research on hallucinations. Psychological Bulletin, 107(1), 82-95. doi:10.1037/0033-     2909.107.1.82

Birchwood, M., & Chadwick, P. (1997). The omnipresence of voices: Testing the validity of  cognitive model. Psychological Medicine, 27(6), 1345-1353.   doi:10.1017/S0033291797005552

Brar, H.K., Vaddigiri, V., &  Scicutella, A. (2005). Of illusions, hallucinations and Creutzfeldt-   Jakob disease (Heidenhain’s variant). 17, 124-126.

Brébion, G., David, A. S., Jones, H., & Pilowsky, L. S. (2005). Hallucinations, Negative   Symptoms, and Response Bias in Verbal Recognition Task in Schizophrenia.    Neuropsychology 19(5), 612-617. doi: 10.1037/0894-4105.19.5.612

Brébion, G., Ohlsen, R.I., Pilowsky, L.S., & David, A.S. (2008). Visual hallucoinatons in             schizophrenia: Confusion between imagination and perception. Neuropsychology, 22(3),   383-389. doi:10.1037/0894-4105.22.3.383

Breen, L.J., & Darlaston-Jones, D. (2010). Moving beyond the enduring dominance of      positivism in psychological research: implications for psychology in Australia. Australian Psychologist, 45(1), 67-76. doi:10.1080/00050060903127481

Brett, E.A., & Starker, S. (1977). Auditory imagery and hallucinations. The Journal Of Nervous   and Mental Diseases, 164, 394-400.

Butler, P. D., & Javitt, D. C. (2005). Early-stage visual processing deficits in schizophrenia. Current Opinion in Psychiatry, 18, 151–157.

Chalmers, D. J. (1996). The conscious mind: In search of a fundamental theory. New York, NY:   Oxford University Press.

Copolov, D.L., Trauer, T., & Mackinnon, A. (2004). On the non-significance of internal versus external auditory hallucinations. Schizophrenia Research, 69, 1-6.

Dorschot, M., Lataster, T., Thewissen, V., Bentall, R., Delespaul, P., & Myin Germeys, I.  (2012). Temporal dynamics of visual and auditory hallucinations in psychosis. Schizophrenia Research, 140 (1-3), 77-82. doi:10.1016/j.schres.2012.06.010

Ferman, T. J., Arvanitakis, Z. Z., Fujishoiro, H. H., Duara, R. R., Parfitt, F. F., Purdy, M. M., &   Dickson, D. W. (2013). Pathology and temporal onset of visual hallucinations, misperceptions and family misidentification distinguishes dementia with Lewy bodies from Alzheimer’s disease. Parkinsonism & Related Disorders, 19(2), 227-231. doi:   10.1016/j.parkreldis.2012.10.013

Freeman, D., & Garety, P.A. (2003). Connecting neurosis and psychosis: the direct influence of   emotion on delusions and hallucinations. Behaviour Research and Therapy, 4(8), 923-  947. doi:10.1016/S0005-7967(02)00104-3

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

www.drjohngkuna.com

The Misattribution of Misattribution: Analysis of the Cognitive models of Hallucinations, Part III

On a different but related front, a study by Aleman et al. (2000) sought to investigate the Perky phenomenon, or the theory that the cognitive mechanisms involved in reality testing are similar between normal control groups and psychotic, hallucinating groups. 243 undergraduates from Utrecht University were screened for a propensity toward hallucinations by the Launay-Slade Hallucination Scale (LSHS). The LSHS purports to measure an individual’s tendency towards hallucinations by posing such questions as, “I often hear a voice speaking my thoughts aloud.” 19 high scoring participants and 17 low scoring participants were selected. Male to female ratios between groups were comparable, and the mean difference between groups was significant: t = 23.7, p < .0001.

The two selected groups were then administered both the Betts QMI Vividness of Imagery Scale and the Marks Vividness of Visual Imagery Questionnaire (VVIQ). Several experimental tasks were administered to both groups. The tasks involved both visual and auditory imagery perception comparison tasks, as well as a musical imagery task (to assess auditory modalities) and a letter imagery task (to assess visual modalities).  While the precise methodology of these visual and auditory tasks varied throughout the experiment, the nature of the experiment required participants to create a mental image in order to make accurate decisions. In the perceptual condition, for example, pictures of the following objects would be presented to the participants: “pumpkin”, “lettuce” and “tomato”. In contrast, in the imagery condition, only the names of the objects were presented—thus, creating the need for the formation of mental images.

With two questionnaires and three experimental tasks (each with two subdivisions of an auditory and visual modality), replication of descriptive statistics here would likely bog down the reader and serve only to distract from the overall argument of this paper. Still, the results of Aleman’s copious work were positive: the researchers replicated earlier results showing that hallucination prone individuals report more vivid mental imagery. The two groups, however, did not differ at all on five of the six experimental imagery tasks. For this reason, Aleman et al. concluded that the—as yet unknown—cognitive processes implicated in reality testing, rather than heightened mental imagery, play a decisive role in hallucinatory events.

Aleman et al.’s introduction ironically provides highlights of the inconsistencies of the current literature regarding the more vivid mental imagery hypothesis in hallucinating individuals. Providing a brief synopsis of the literature, the researchers note how Slade (1976) and Mintz and Alpert (1972) found that hallucinating individuals experienced more vivid mental imagery compared to their non-hallucinating counterparts. Brett and Starker (1977) and Starker and Jolin (1982), on the other hand, unable to replicate the above findings, could not discern evidence of more increased vivid mental imagery in hallucinating vs. non-hallucinating patients. Aleman et al. argue that the latter two studies failed to replicate previous findings because both studies were concerned with “introspective measures of imagery, which are limited to the subjective experience of imagery.”

The underlying assumption in Aleman et al.’s critique highlights the present argument uncannily. With a lacuna of a systematic epistemological presentation and his association of internal events with subjectivity, Aleman et al.’s position smacks suspiciously of positivism. That is, Aleman et al. seem to imply that what is “out there” is objective and real, and what is inside is subjective and faulty.

Space does not permit a complete analysis and defense of the way in which internal data, of themselves, are not necessarily subjective or less real than external data. The curious reader is refered to Bernard Lonergan’s seminal work, Insight. Regardless, the original argument of this paper—that the success of future cognitional research regarding hallucinations derives by securing it in a common epistemological framework—is clearly shown. Aleman’s approach, and subsequent critique, differs from Starker and Jolin’s (1982), who in turn differ from Mintz and Alpert (1972), who in turn, no doubt, will differ from future researchers. The lack of unity comes not from their respective choice of instruments, or from their sample size, or even the statistical tests chosen, but rather from their fundamental differences of epistemological and cognitional theories.

A further explanation for the possible cognitive mechanism underlying hallucinations is the liberal response bias, which claims that hallucinatory patients will more likely report imaginary events as real. That is, the tendency to make false (and often early) detection in cases of doubt or uncertainty of the presented stimuli has been found to be correlated with hallucinating individuals. As is common, this phenomenon has been replicated in numerous studies throughout the literature. A 2005 study, again by Brébion et al., sought to extend this theory using new measures. As with Aleman et al. above, Brébion et al. similarly introduce their research by indicating the conflicting results between their research and the literature. Specifically, Brébion et al. note how Ragaland et al. (2003) reported findings that indicate a liberal response bias is associated with delusions, not hallucinations. Heinrichs and McDermid-Vaz (2004), however, were unable to detect any relationship between false word recognition and global positive symptoms scores in individuals with schizophrenia. Brébion et al. naturally conclude that Heinrichs and McDermid-Vaz (2004) misinterpreted the data, and undertake the current studies to confirm their hypothesis.

In order to test the liberal response bias hypothesis, Brébion et al. administered a word recognition test to 40 in and out patient individuals with schizophrenia. After being assessed for both positive and negative symptoms, participants were shown 16 concrete, simple words. Each list contained 8 high frequency words and 8 low frequency words. Participants were instructed that they had 45 seconds to memorize the list, and were required to read the list aloud. After a five minute pause the participants were given a blank sheet and asked to transcribe as many words as possible from memory. They were then provided a recognition sheet containing the 16 actually seen words as well as 16 distractor words, and asked to circle the words from the original list. A second word list was provided with similar instructions. In this second session, however, participants were provided the recognition sheet (with accompanying distractor words) immediately following the presentation of the original word list.

As predicted, Brébion et al. found a significant correlation between hallucination scores and response bias, and the researchers interpreted this to imply that higher levels of hallucinations are related to the propensity to make more false recognition of words not actually presented in the list. The researchers found further that anhedonia had a significant relationship with a reduction in response bias—indicating the opposite effect for that of hallucinations. During data analysis, participant scores on the National Adult Reading Test (NART) were factored, in an attempt to control for the effects of memory and verbal intelligence.

Two distinct limitations are apparent in this work. First, as in the Aleman et al. critique, requiring participant vocalization of the word unnecessarily inserts an external component to the measurement of an internal event. Second, Brébion et al. interprets the results to indicate that the liberal response bias exhibited directly implicate an external source. The problem with this assumption is that it is simply not supported by the literature. Although several studies on hallucinations indicate that patients attribute their hallucinations occurring “from outside” (ie, externalizing), there are equally ample cases where

hallucinations are reported to be from “inside” (Copoloy, Trauer and Mackinnon, 2004; Junginger and Frame, 1985). That is, Brébion et al. seem to assume that hallucinations must have an externalizing component to be a hallucination. Finally, as the literature itself shows inconsistencies, perhaps the fundamental issue at hand is the use of a paradigm that could embrace the constructs relevant to this research—concepts such as self vs. other, subjective vs. objective reality, and internal vs. external events.

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

www.drjohngkuna.com

The Misattribution of Misattribution: Analysis of the Cognitive models of Hallucinations, Part II

Our starting point is a 2008 study by Brébion et al. The researchers present a theory of source-memory deficits as possible etiological explanation for VH in individuals with schizophrenia. The Source Memory deficit theory argues that VH essentially arise from a lack of intact reality testing. In this paradigm, VH are a result of the individual’s inability to differentiate between imagination and perception—similar to the theory that auditory hallucinations arise from externalization of internal speech (Allen et al., 2004). The authors, therefore, designed a reality monitoring perception test that would measure an individual’s ability to distinguish perceived from imagined images. The researchers hypothesized that clients with VH would exhibit a greater tendency to falsely remember seeing pictures that had in fact been presented as words only.

The present study contained 41 patients with schizophrenia and 43 healthy individuals for the control group. There was no significant difference of age, gender, education, ethnicity or verbal IQ between the two groups. Verbal IQ was assessed by administration of the National Adult Reading Test (NART). Positive symptoms were assessed by administration of the Assessment of Positive Symptoms (SAPS).

The researchers employed the Battig and Montague set (1969). An invaluable tool for researchers across multiple disciplines, this instrument is a categorical norming set which purports to present exemplars and prototypes of various culturally conditioned objects. Sixteen categories from the Battig and Montague set were presented. Only common objects were used—for instance, “elephant” and “tiger” for the category of animal. Participants were shown two cards for each instance within a category. One card displayed only the word defining the object; the other card provided the picture of the object with an accompanying verbal label. The experimenter indicated the category name (“types of animals”) before presenting both cards. In order to ensure encoding, the participants were required to verbally name the two objects, as well as provide a third example. Unfortunately, participant examples were not included in their research. After an approximately 5 minute pause, a recognition test was administered. As the experimenter read aloud the list of objects as well as distractor items, the participants were required to indicate whether each item had been presented as a word, a picture, or not at all. Immediately following the recognition test, a reality-monitoring test was given. As the experimenter read the list of the 32 target items, participants were required to indicate whether a picture of the word had been displayed or merely the word. Participants were informed that all items in this test had been previously presented.

Data analysis seems to confirm the misattribution theory. The researchers found a significant interaction of subgroups and misattribution. Specifically, they found that those participants reporting VH made significantly more misattributions to pictures than the other patients, t(39) = 2.79, p < .01.

The authors note the limitations characteristic of a study on VH in individuals with schizophrenia—namely, a small sample size. They further note that, procedurally, the presentation of images and words categorically (“type of animals”) is limiting insofar as it may provide memory cues, and urge that future replication studies consider employing a non-systematic presentation of images.

Two further limitations may be equally noted. First, the researchers employed the Battig and Montague set (1969) to categorically delineate everyday objects, which itself is an updated version of the Connecticut Category Norms originally published in 1957 by Cohen, Bousfield, and Whitmarsh (Overschelde, Rawson, and Dunlosky, 2004). More than 40 years after its creation, the Battig and Montague set should most likely have been substituted for a more current standard. The Battig and Montague set, for example, includes such anachronisms as “rubbers” for shoes, and the “waltz” for a popular style of dance. A replication of Brébion’s above work using the Overschelde et al. instrument, which boasts new categories, new measures, as well as latencies for generated responses, would be highly desirable.

Second, with respect to the aforementioned epistemological framework, it is not clear to me why the researchers required participants to verbalize the image on the card. While the integration of contemporary cognitive theory into the research is laudable, the difficulty with this method is that it produced both an internal and external vocalization. Although still self-generated, this external vocalization could be disruptive to the process of understanding how only internal events (whether words or images) relate to misattributions.

A less unique, but particularly relevant study for the purposes of this paper, concerns the role of affect and intentionality as predisposing factors for a hallucinatory experience. Based in part on previous work by Gauntlett-Gibert and Kuipers (2005), that indicated the activating role of affect in hallucinatory experiences, this 2012 study by Oorschot et al., employed the Experience Sampling Method (ESM). The ESM purports to provide first person empirical feedback on emotional states by means of a structured, self-report likert scale. While proponents of the ESM method argue that it offers the advantage of providing real-time responses, instead of relying on recall and the possibility of memory deficiencies, opponents readily cite the inherent difficulties in any self-report measure, perhaps especially in patients with psychotic disorders.

Nonetheless, in this study, 184 participants (71% male) with psychosis spectrum disorder were provided a digital stop watch and assessment booklets that were collected daily. Ten times daily for six consecutive days, the programmed stop watch would signal at random intervals ( = 90 minutes) between 7:30 am and 10:30 pm, alerting the participant to begin the assessment. The ESM assessment consists of open-ended questions and a 7-point Likert scale questions aimed at measuring the participant’s emotional state, psychopathology, and environment. Likert scale questions aimed at capturing psychopathology included statements such as, “I hear voices” and “I hear phenomena”. Similarly, likert scale questions to assess emotional state were based on mood adjectives such as “I feel cheerful/satisfied/relaxed” and “I feel guilty/anxious/sad.” During pre-testing instructions, participants were required to complete a single ESM assessment to gauge their task comprehension. The experimenters regularly contacted the participants throughout the trial in order to assure compliance, and participants who responded to less than one third of the emitted signals were not included in the study. Finally, Oorschot et al. report literature citing the validity of the ESM measurement, in both normal control groups as well as psychotic populations.

Analysis revealed that, of the commendably large sample size for this population, 30% reported AH and 25% reported VH. Further, of the 1,111 instances of reported hallucinatory events, there were 196 VH and 399 AH. Participants reported 117 moments of cannabis use out of 7,399 total reported instances (9 instances were related to VH, and 31 instances related to AH).

In terms of the relationship of emotional state to hallucinatory experiences, Oorschot et al.’s predictable results found that participants expressed significantly higher negative affect (and subsequently significantly lower positive affect) during a hallucinatory event. More specifically, patients reported that VH were preceded by a decrease in positive affect. Accordingly, future research in this domain would be highly improved by the use of emotionally charged stimuli. The previously discussed Brébion (2008) article, for instance, would seem more successful if the pedestrian words and images presented (for instance, “elephant” for type of animal) were replaced with more emotionally relevant stimuli (religious or personally relevant words seem applicable).

The limitations of self-report nature of this study notwithstanding, the relationship of anxiety to the onset (and duration) of both AH and VH is significant insofar as it intersects and confirms prior research on the role of intentionality and affect in hallucinatory experiences. Prior research has already well-documented the relationship between affect and hallucinations (Gauntlett-Gilbert and Kuipers, 2003; Birchwood and Chadwick, 1997), specifically implicating anxiety and depression in the genesis of hallucinations (Freeman and Garety, 2003).

Still, observing a correlation between the variables of anxiety and hallucinations is one thing—accounting for the cognitive processes underlying this relationship is quite another. The limitation of the absence of a theory of knowledge guiding this research is reflected in the inability of researchers to construct experimental procedures with which to test specific cognitional theories. That is, as was noted above, the vast and steadily growing literature on cognitional theories of hallucinations seems primarily to confirm previous similar studies. More recent literature, failing to provide an epistemological foundation and focusing instead on new measures, different instruments, or higher sample sizes, has thus far only been able to replicate previous findings. Scientific progress, at least in a Kuhnian perspective, will require explication and unification of a theory of knowledge from which more accurate experimental models can be produced.

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

www.drjohngkuna.com

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