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Clinical Psychiatry, Psychopharmacology, and Anomalous Experience

• Psychiatric Interpretations of Subjective Paranormal Perception Vernon M. Neppe
• Multiaxial Classificatory System for Anomalous Experience Vernon M Neppe
• Culture, Psychopathology and PSI: A Clinical Relationship Vernon M. Neppe and Michael Ewart Smith
• Out of Body Experience: A Phenomenological Categorization Vernon M. Neppe

This article is reproduced by kind permission of the Parapsychology Foundation in New York, who published this originally in the book "Psi and Clinical Practice (1989)" (pages 145- 163, 1993), Editors Lisette Coly and Joanne McMahon. This was the proceedings of an international conference held in London England. Although checked for accuracy it is possible that reference numbers or other typographical errors have arisen. Nevertheless, as this paper reflects the pioneering work in the area of subjective anomalous experience in relation to clinical psychiatric frameworks, it may be of enormous importance to phenomenologists and researchers and it is reprinted here for academics.

At that stage, Dr Neppe was Director, Division of Neuropsychiatry, University of Washington, Seattle, Washington, United States of America.

Clinical Psychiatry, Psychopharmacology, and Anomalous Experience

Vernon M. Neppe MD, MB, BCh, MMed (Psych), PhD (Med), DPM, FF. Psych (SA)

At that stage, Division of Neuropsychiatry, University of Washington, Seattle, Washington.

The history of psychiatry is riddled with attempts at unifying psychiatric diagnosis. More than a hundred years ago (1860), psychosis was summarized very simply by Heinrich Neumann: "There's only one kind of madness, and we call it insanity¹." Over the next fifty years, this broad conceptualization was insufficient. Instead, numerous labels were placed onto mentally ill patients, such that psychiatric diagnosis was at its most varied and most scientifically inappropriate.

What has historically been perceived as a major breakthrough in psychiatry occurred in the 1890's: Emil Kraepelin's discovery of the term Dementia Praecox². This condition was renamed schizophrenia in 1911 by Eugen Bleuler³. Bleuler emphasized specific symptoms occurring at specific times, and the conceptualization of a split between cognitive and emotional functions. This differed from Kraepelin's conceptualization of a deteriorating illness occurring over many years, presenting in the young, and, ultimately, exhibiting features of intellectual deficit². These two conceptualizations of schizophrenic illness reflect prevailing philosophies pertaining to the importance of cross-sectional symptoms (i.e. symptoms occurring at a specific moment in time) and longitudinal features (i.e. symptoms occurring over periods of many years reflecting course of illness). It was with this conceptualization in mind that Kraepelin (1922) subdivided major psychiatric illness into three, namely: dementia praecox, manic depressive insanity, and epileptic insanity¹.

It is worthwhile reflecting that our current classifications of psychosis are even more limited than this, and emphasize two major conditions: schizophrenia and affective (or mood) disorder (either bipolar illness or unipolar major depression)⁴. From these two major conditions arises a variety of others: for example, in between is so-called "schizoaffective disorder"; when there is suspicion of organic impairment, we talk of "organic delusional syndrome" or "organic hallucinosis"; and inability to classify these conditions under any of these broader headings results in the diagnosis of "atypical psychosis". Even worse, this term "atypical psychosis" no longer exists in the Diagnostic and Statistical Manual, (Third Edition, Revision) of the American Psychiatric Association, the bible of psychiatric diagnosis, and has been replaced by "psychosis, not otherwise specified"⁴. A large proportion of our current psychiatric diagnoses do not fit well into any of these Procrustean frameworks, where specific clinical criteria have been worked out, and where patients are expected to be placed within diagnostic categories which may have dubious clinical relevance. Psychiatric diagnoses today are at times a dumping ground for the diagnostically destitute.

This cynical viewpoint is based, unfortunately, on empirical experience. Some 15 years ago it was said that the easiest way to cure schizophrenia was to travel across the Atlantic. This reflected the diverging views of this condition in American and European psychiatry¹. Fortunately, criteria unification at the clinical level has led to more consistent diagnostic labels. But these are only very relative, and every week my colleagues and I see patients who have a prolonged psychiatric history with a variety of different previous diagnostic labels. First admission, borderline personality disorder; second admission, schizoaffective illness; third, schizophrenia; fourth, mania; fifth, atypical psychosis; sixth, maybe one of these earlier conditions, maybe organic delusional disorder. Clearly diagnostic nomenclature at this point in time, from the psychosis framework, is in difficulties, and the same applies to the more limited neurotic kinds of illness.

This emphasis on the deficiencies of current psychiatric nomenclature is made for another reason. When groups of symptoms such as anomalous experiences, or experiences which are out of the ken, the training, the knowledge base, and the conventional framework of clinical psychiatry appear, these features are perceived frequently as psychopathologic, and attempts are made to place the experience within the frameworks of one of these broader diagnoses. Thus "out of body" experience can, at its broadest psychopathologic level, be perceived as "extreme ego splitting, with marked derealization and depersonalization, and delusional out-of - touchness with reality."⁵ Precognition can be perceived as a primary delusional idea, with alienation, passivity, or reference phenomena. The same may be said for other forms of contemporaneous clairvoyance. Telepathy can be perceived within the framework of thought- broadcasting or thought insertion, both "first-rank symptoms", outlined by Kurt Schneider, 50 years ago⁶. Trancelike states, and writing automatisms, can be perceived as extreme dissociative phenomena, or as extreme passivity phenomena within the framework of psychosis⁷. These symptoms may in fact be interpreted correctly under certain circumstances: Clearly patients who are psychotic may misinterpret reality, and it is not uncommon for such patients to believe themselves psychic, and to act out their delusions⁸. They may well join subgroups who will accentuate such belief systems. This does not, however, imply that all subjects with subjective paranormal experience, or anomalistic experience, are psychotic, yet psychiatrists have in general attempted, without empirical studies, to insert such symptoms into the framework of psychopathology and abnormality^8,9. What alternatives exist to this current state of affairs? We can use approaches, such as those of Robert D. Laing, or Thomas Szasz, and perceive the patient as not necessarily pathological, but his interaction with society as being damaging because of societal labelling and sociocultural misinterpretations^10,11. This, therefore, shifts diagnoses out of the framework of the psychological to the sociocultural.

An alternative is to approach diagnostic nomenclature at two levels – firstly, the functional, and secondly, the psychopharmacologic. I believe that these together form an appropriate approach. Using the functional framework, one perceives the patient in the context of his biological, psychological, social, family and cultural functioning. One perceives him as a biopsychofamiliosociocultural system¹². Defects at any of these levels producing noncoping, or non-optimal coping, can be perceived as psychopathologic. No matter how strange the patient's experiences are, they are not perceived as abnormal unless they distinctly interfere with the patient's functionality and coping skills¹³. This is a good, basic, empirically-derived definition, which allows paragnosts to experience realities which others may not be able to conceive of, but which do not produce labels of psychopathology.

The second, related approach, actually fits within this first, and involves emphasizing the biologic components to psychiatric disorder.12A great deal of research has occurred in the modern era, trying to find biological correlates for such conditions as schizophrenia and affective illness. Specific tests have attempted to differentiate these conditions - at this point, unsuccessfully.

Less emphasized, and a theme of my latest book¹², is the marriage of psychopharmacologic responsiveness and toleration of psychotropic medication to psychiatric diagnoses. It is largely irrelevant to me whether or not a patient is necessarily labelled schizophrenic, schizoaffective illness, organic delusional syndrome, or mood disorder. If that patient responds to a specific medication, or combination of medications, I believe the cluster of patients is far more homogeneously expressed by this responsiveness to specific combinations of psychotropic medication, irrespective of diagnosis^14,16,17.

Moreover, we have a very conventional, useful, underused and underemphasized diagnostic test. It is said the "normal person would not handle such crazy medications," and this is quite true: High doses of psychotropic or antipsychotic medications are tolerated only by patients who are psychotic, have severe personality disorders, have drug dependency problems, or have an extremely active liver, (allowing very rapid breakdown), or a poorly functional gastrointestinal tract (at that point allowing nonabsorption). The average person, in the vast majority of cases, does not tolerate antipsychotic doses of neuroleptic medication^15,17. This implies that we have specific biochemical diagnostic traces that differentiate normal from psychotic conditions¹⁷.

Thus, two principles exist in differentiating out normative from abnormal behavior. First, the definitions of coping at a functional level¹³ and secondly, psychopharmacologic toleration and responsiveness as an underlying indicator and expression of biochemical abnormality, which produces, not only the psychopharmacologic epiphenomena, but also the epiphenomena of specific clinical symptoms^18,19.

This limitation in expression of symptoms by the brain is also appropriate with regard to subjective paranormal experience. So, for example, it is well demonstrated that out-of-body experience, or autoscopic experience, may be induced by stimulating certain areas of the temporal lobe of the brain^20,21. This may be mechanistically quite different from out-of- body experience as it occurs in the paragnost. The limited expression is a final common pathway^22,8. Great dispute exists with regard to a second final common pathway: the commonality of the near-death experience⁸. Similar comments can be made with regard to déjà vu¹⁸ and also with regard to hallucinations¹⁹.

Hallucinations are particularly relevant because using a psychiatric model they persistently are interpreted as expressing major psychopathology, generally psychosis²³. Yet there are normal hallucinations. Well-known, for example, are so-called hypnagogic and hypnopompic phenomena occurring in normal subjects and also in the narcoleptic, and not regarded as pathologic as such¹⁹.

Less well-known are the surveys by Sidgwick and associates 24 and 50 years later by West²⁵ who demonstrated, in a very large survey (Sidgwick, approximately 10,000; West, more than 1,000) of normal people, that the incidence of hallucinations, predominantly visual hallucinations, occurring at least once in a lifetime in the population, is of the order of 10-14%. These visual hallucinations cluster around a death, even when that death is unexpected and unknown¹⁹. The significance of this finding is relevant, not only to parapsychological research, but to the psychiatric context of a major trauma being linked in terms of reported past memories of a strange experience, such as a visual hallucination. This, therefore, would potentially accentuate innacurate anecdotal memories^26,27,28.

Given the small ways of expression of the brain, some of which may be subjective paranormal experiences (SPE)²⁹, it is important to analyze which psychiatric diagnostic groups are most likely to exhibit SPE, whether these have been perceived as pathologic or normal. Table 1 lists the major groups dealt with.

Schizophrenics

Schizophrenics and other psychiatric patients with similar psychoses, like acute exacerbations with schizoaffective illness, and patients with manic episodes, often present, with hallucinatory and delusional experiences that are very much linked to the sub-culture⁷. If they are religious, they may perceive themselves as Jesus, or as Judas, and may therefore want to act out, in a grandiose or persecutory manner. Those with mystical type experiences may perceive themselves as higher beings, or alternatively, may regard themselves as being extremely psychic, and having clairvoyant and telepathic abilities^30,7.

Such symptoms are particularly relevant because they reflect the Schneiderian "first-rank symptoms" of psychosis, namely: passivity phenomena and alienation⁶. Alienation and passivity phenomena relate to a distortion of the patient's ego, whereby influences are received from outside producing an influence on thinking, emotions, drives, impulses or bodily functions. When not only influence occurs, but the outside influences are perceived by the patient as controlling these phenomena, the experiences at times become alien. Such features are hallmarks of psychosis, and the major component is the reference to self, with distortion of ego boundaries^31,32.

Logically an extension of this distortion of self is the perception that the patient is receiving information from outside by telepathy or clairvoyance; that others are reading his mind; and that he can read others' minds; that his thoughts can be broadcast; and that there is therefore no need to communicate by speech. Patients may develop a fixed delusional system pertaining to their being psychic, or being able to predict the future. It is interesting that such patients are unable to substantiate any factual evidence, and when they do give examples, the examples are usually inconsequential, and sometimes non-sequiters. ("I knew I would see my father, and I did, three weeks later." Or: "I knew I would see my father, and, when I did, I was aware that he was the devil.") These features therefore have links with psychosis. Very often the patient talks in vague terms or contradictory terms, and when confronted in this regard, will attempt to explain the phenomena in an even more delusional kind of framework^8,13.

These patients do not cope at the biopsychofamiliosociocultural level, and they will tolerate high doses of neuroleptic agents -fulfilling the two criteria I have suggested for psychosis. Moreover, this antipsychotic group of drugs will assist in allowing them to attain greater awareness of reality. Thus, the schizophrenia-like psychoses, and, at times, manic illness, may present with a grandiose component, looking like psychic experiences, but manifesting other groups of vegetative and cognitive symptoms, which are clearly inappropriate and associated with decompensation and impaired functioning of the patient.

Hallucinogenic Mobilized Psychoses

The second sub-group relates to patients who have had hallucinogen drugs, either during their episode acutely, or in the past. Two commonly used ones are LSD and PCP. These drugs produce a schizophrenia-like state, either acutely or in more chronic form, but with certain special differences. Very often the mystical element, in terms of mind expansiveness, is particularly exaggerated, and this produces distortions in appreciation of time perception. Such distortions are common in schizophrenics, but hallucinogen-mobilized psychosis is the prototype example¹.

These patients have difficulty differentiating seconds from hours, days from minutes. Their estimate of time is very wrong. They exhibit a certain apparent mystical expansiveness, whereby they describe feelings of all-knowing, and awareness of realities that they could not even have believed were possible: these experiences may be extremely frightening, or may be associated with euphoric qualities. At times they talk of flashbacks back to such experiences. All these experiences may be reflecting their acute psychotic reality, either under the acute influence of hallucinogens, or through their presenting with a more prolonged schizophrenia like kind of illness, which seems to have initially been mobilized by hallucinogens. This condition does not have the typical negative features of schizophrenia: the withdrawal, the apathy, the autism, the out-of-touchness with reality components, and the substantial lack of insight. Instead, these patients have some insight, are aware that something is strange and that something is different. They have positive hallucination type features, but very often they have visual hallucinations as opposed to the classical, complete auditory hallucinations one sees in schizophrenia^1,19.

Such cases are at times more difficult to differentiate out in terms of psychic experiences because the pseudo-philosophicality and their mind expansiveness at times makes them look like geniuses or extremely intelligent people, until one listens carefully to the quality of thought, and the distortion in terms of interpretation of reality base.

Subjective Paranormal Experience Psychosis

The third group of conditions, of importance at a clinical level, is Subjective Paranormal Experience Psychosis. (SPE Psychosis)¹³ This condition was originally described by myself in the early 1980's to fill a gap in the literature relating to people who gave a history of ostensibly genuine subjective paranormal experiences, starting in childhood. However, at some point in their early adulthood, they presented with acute psychotic decompensation.

The major feature that had changed - heralding the psychosis - related to self-reference ideation. Suddenly their awarenesses, their "psychic experiences", were not about others or about the things of little relevance to themselves; instead , they started having experiences about themselves producing enormous distress, because of the dysphoric nature of such experiences such as beliefs that they may die⁸.

This condition was characterized by a cluster of features as follows:

1. onset of subjective paranormal experiences (SPEs) during childhood, often before the age of five, certainly before the age of ten;
2. history of numerous subjectively well-validated subjective paranormal experiences (SPEs) which related to others, never to themselves.
3. history of onset of a psychotic episode at any stage of one's life manifesting as self-reference "delusions" pertaining to at least one of these subjective paranormal experiences;
4. such an SPE may relate to the subject's death;
5. a phase of acute turmoil precipitated by self-referential SPEs with the conviction that the SPE is true, but turmoil because it cannot be proven;
6. a phase of very sudden recovery after the SPE has been shown to be false;
7. absence of progression with no phase of deterioration longer than six months;
8. absence of family history of major psychiatric illness;
9. presence, at times, of family history of subjective paranormal experiences;
10. or alternatively, marked antagonism within the primary family group to psi;
11. absence of response to the appropriate management of the conventional differential diagnosis which is most reasonable;
12. no previous psychiatric history;
13. maintenance of congruous and appropriate affective responses;
14. exclusion of physical causes¹³.

Trancelike Experiences: Paragnosts and Hysterics

The fourth group of subjects have trancelike experiences. Again, there is a subdivision of those that are coping and functional, and apparently claim trancelike experiences as part of their mediumistic communications. These subjects, in general, have subjective paranormal experiences generally of very diverse kinds, such as out-of-body experiences, and various kinds of contemporaneous, retrocognitive and precognitive clairvoyant or telepathic type experience, either in waking reality or during dreams. They may or may not claim psychokinetic experiences. Their trancelike experiences are usually associated with an alteration or defect of consciousness and they have an amnesia in general for any verbalizations that occur during this phase. This amnesia is not, however, invariable, and it is not uncommon for these subjects to exhibit a dual consciousness. The quality of verbalization or vocalization may vary both in kind of voice (i.e., own or other) and in degree of veridical information^5,7.

As opposed to this "normal" sub-group is a second group of patients who have hysterical dissociative episodes whereby they assume a different form of identity or behavior and exhibit amnesic components. This generally follows on a major stress in their life, and has an acute onset and relatively acute offset. At a later point in time there may be patchy memories, and generally these episodes can be recreated in such altered states of consciousness as hypnosis. The core component of such conditions relates to the appropriateness of the psychodynamics⁷.

The problem with the two subgroups of these conditions is that it is possible the subject may exhibit trance kinds of experiences, and also hysterically dissociate. In any event, clearly any vocalizations obtained during so-called psychic trance experiences may well be contaminated by underlying psychodynamics and emotional state of the subject²⁶.

The Psychotic Psychic

The fifth group is similar to the first, the group of patients with subjective paranormal experience psychosis. But in this instance, it is approached from the other end. Patients who are psychotic or exhibit other forms of what is perceived as special, bizarre pathology, such as seizure disorders, are accepted within the subculture, or within their preliterate culture, as having special mystical abilities. They are trained to become indigenous healers, witch-doctors, sangomas, or shamans⁷.

This subgroup of patients is biochemically distinct because they exhibit toleration of high doses of antipsychotic agents, and need control of their symptoms with psychotropic medication. Alternatively, their mystical behavior–seizures–responds to anticonvulsants⁷.

Non-epileptic Temporal Lobe Dysfunction and Temporal Lobe Epilepsy

There is an important, sixth group of patients with non-epileptic temporal lobe dysfunction and with temporal lobe epilepsy who may hypothetically manifest subjective paranormal experiences. This hypothesis is based on the reverse research, whereby I demonstrated, in the early 1980's, that there is a very substantially increased incidence of possible temporal lobe symptoms in subjective paranormal experients^{20,33, 34,35}. These are subjects who claim a large a number of SPEs of at least 4 different kinds, and these SPEs have been subjectively validated on at least 16 occasions. They form the tip of the iceberg of apparent substantial paragnosts. Without exception they manifested temporal lobe symptomatology, both relating to their SPEs (i.e., a state phenomenon), and also, independent of their SPEs (i.e., a trait phenomenon)³³. This suggested that an anomalous pattern of temporal lobe functioning may allow them to experience an exogenous or endogenous reality, which most people are unable to experience²⁰.

It is interesting that the "normal" subjective paranormal experients, however, exhibit possible temporal lobe symptoms of qualitatively different or unusual kinds. They experience, for example, pleasant, perfumy, or flowery olfactory hallucinations³⁶, in addition to experiencing, at times, the more common olfactory hallucination of temporal lobe epilepsy, namely, unpleasant, burning, or rotting smells^36,37. In addition, these patients do not experience temporal lobe epileptic type déjà vu, but subjective paranormal experience déjà vu¹⁸. These point to qualitative differences that may still localize the area of integration of SPE to the temporal lobe, which, in addition, for theoretical reasons, would be a good choice^{20,37, 38,39}.

Consequently, I set out to establish whether or not the reverse was true. Do patients with non-epileptic temporal lobe dysfunction, or patients with temporal lobe epilepsy, have more subjective paranormal experiences? Unfortunately, this research is not easy. Firstly, the great majority of the population, generally 70-90%, in numerous surveys in different countries, claim at least one subjective paranormal experience in their lives, with the consequence that the occurrence of SPEs in this population is of no great significance^40,41. What may be more relevant is the occurrence of frequent SPEs. This is common ground in patients with temporal lobe dysfunction and temporal lobe epilepsy.

It is interesting that, in my experience, when these patients are placed onto anticonvulsant medication, such as carbamazepine (tegretol), they invariably improve, in terms of their temporal lobe symptomatology, and this improvement parallels the diminution or non-occurrence of subjective paranormal experiences, as well as a diminution in creativity, in musical ability, and ability to write poetry. Results at this point relate to my open studies and my pilot experience with these patients involving careful evaluations. The numbers are extremely low, in that the majority of patients with temporal lobe epilepsy do not want to talk about their SPE symptoms lest they are labelled as uncontrolled. There are numerous constrictions and restrictions to such discussions because of the medical and legal implications of operating machinery and driving vehicles for patients who are still seizing. This appears to be an extremely promising direction of research, however.

It is interesting that we have described a family with coexistent temporal lobe dysfunction and subjective paranormal experiences^{42, 43}. It appears that a family history of epilepsy is a common phenomenon amongst paragnosts. Again, this is fraught with diagnostic difficulties because the patient with epilepsy is seldom available for further investigation. There are anecdotal components to this.

Perspective

This paper has attempted to evaluate psi in the clinical psychiatric context. Clearly the phenomenon occurs. At times the description appears to have psychotic elements. There is always a psychodynamic flavoring to experiences of various kinds, but the essence of pathology appears best based on the biopsychofamiliosociocultural model of the patient not coping, and the patient being able to tolerate, and respond to, appropriate psychotropic medication, particularly neuroleptic medication or anticonvulsants, such that this may implicate underlying biochemical traces.

It appears that the area of the brain most involved is the temporo-limbic system. However, clearly psychodynamics are of enormous relevance in any psychotherapeutic relationship, and attempts at explaining phenomena may involve psychodynamic explanations, even in the organic patient.

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