Clinical Psychiatry, Psychopharmacology, and Anomalous Experience
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 abnormality8,9. 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 misinterpretations10,11. 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
diagnosis14,16,17.
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 medication15,17. 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 symptoms18,19.
Expression of such clinical features is limited by the brain to a few such
experiences. The patient may experience hallucinations. He may experience
symptoms pertaining to delusions and thought disorder or emotional
changes, such as depression or euphoria. Alternatively, he may experience
anxiety, agitation, aggression, alienation and distortion in terms of
caring experience. He might experience differences at the psychomotor
expression level, and at the motivation level. In more extreme cases, he
may experience alterations of consciousness, insight, judgment, and overt
dangerousness to himself or others. Finally, he may experience specific
focal cerebrocortical features, such as apraxia or aphasia.
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 brain20,21. This may be mechanistically quite different
from out-of- body experience as it occurs in the paragnost. The limited
expression is a final common pathway22,8. 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 memories26,27,28.
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.
Table 1 Psychiatric Conditions Most Likely Associated
With Subjective Paranormal Experiences
Group 1, Schizophrenics |
Group 2, Hallucinogenic Mobilized Psychoses |
Group 3, Subjective Paranormal Experience Psychosis |
Group 4, Trancelike Dissociative Phenomena |
Group 5, The Psychotic Psychic |
Group 6, Epilepsy and Non-Epileptic Temporal Lobe Dysfunction |
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 abilities30,7.
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 boundaries31,32.
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 framework8,13.
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 schizophrenia1,19.
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:
- onset of subjective paranormal experiences (SPEs)
during childhood, often before the age of five,
certainly before the age of ten;
- history of numerous subjectively well-validated
subjective paranormal experiences (SPEs) which related to
others, never to themselves.
- 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;
- such an SPE may relate to the subject's death;
- 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;
- a phase of very sudden recovery after the SPE has
been shown to be false;
- absence of progression with no phase of deterioration
longer than six months;
- absence of family history of major psychiatric illness;
- presence, at times, of family history of subjective
paranormal experiences;
- or alternatively, marked antagonism within the
primary family group to psi;
- absence of response to the appropriate management
of the conventional differential diagnosis which
is most reasonable;
- no previous psychiatric history;
- maintenance of congruous and appropriate affective responses;
- 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
information5,7.
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 behaviorseizuresresponds 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 experients20,33, 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 smells36,37. 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 choice20,37, 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 significance40,41. 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 experiences42, 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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