In Schizophrenia Part 1, we noted that the APA lists hallucinations as one of the primary “symptoms” of schizophrenia. The APA defines an hallucination as follows:
“A sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of the relevant sensory organ.” (DSM-IV-TR, p 823)
In other words: seeing, hearing, smelling, tasting, or feeling something that isn’t really there. Typically the individual who has been “diagnosed” with schizophrenia reports that he hears voices that accuse him of some wrong or exhort him to some action, and sometimes threaten him with punishment or retribution.
A number of points need to be made.
Firstly, it has been established for many years that people who report auditory hallucinations are in fact talking to themselves. Sensitive monitoring equipment can pick up the minute vibrations of the vocal chords, and when these signals are amplified, it is possible to actually hear what the individual is saying to himself.
Secondly, apart from the kind of monitoring equipment mentioned above, the only way you can know if someone is hallucinating is if he tells you so or if he gives you some overt indication, e.g. cocking his head to one side as if listening to a voice from the other side of the room, etc.. Now the fact is that almost everybody engages in self-talk. Most of us, however, keep it private and even display a small measure of embarrassment when “caught” engaging in this activity. The difference between “ordinary” people and “hallucinators” is that the latter reveal the process publicly by a variety of methods.
The vast majority of people realize that their self-talk is just that: talking to themselves inside their heads. And although we may enjoy this activity, we afford more importance and pay more attention to external stimuli, i.e. the real world. And because the real world seems more important and relevant to us than our self-talk fantasies, we assume that this is the way it should be for everybody. The fact, however, is that paying attention is what behavioral scientists call an operant. We pay attention to certain things in life because the act of paying attention to them is rewarded, and we routinely ignore other material because there is no pay-off for attending to it. For instance, if you are driving in city traffic, it is worth your while to pay attention to traffic lights, other vehicles, and pedestrians. It is not worth your while to pay attention to windblown trash swirling and eddying in the gutters. In fact, if you’re paying more attention to the latter than the former, you will likely incur some very negative consequences. However, if you are sitting on a bench eating your lunch, you can watch the windblown trash all you like. Similar considerations apply to almost every aspect of life. If you’re in a meeting at work and the boss is talking, it generally makes sense to pay attention to what’s being said and to put the fantasy life on hold, etc., etc.
But what needs to be remembered in these considerations is that we assign more priority to external reality than internal fantasy only because historically this perspective has brought us success. We pay attention to the boss because in our experience this brings rewards. The reward may simply be a smile of appreciation, but because of our training and experience, we see these tiny rewards as important and cumulative. They’re like green stamps: save up enough and you get a prize.
For a person who has experienced little but failure, suffering, and grief, however, the situation is markedly different. His experiences tells him that it doesn’t really matter what you do or what you pay attention to, it all ends badly anyway. In this kind of context, a retreat to the internal fantasy world becomes very understandable and, in extreme cases, almost inevitable. The prioritization of internal over external stimuli is not in itself a pathological process, but is rather a natural and understandable consequence of repeated and significant failure. So young people who go out in the world lacking the kind of basic skills mentioned in my post on schizophrenia Part 1 are at high risk for experiencing profound failure in the three great challenges:
– emancipation from parents
– finding a partner
– launching a career
For these individuals, paying attention to internal stimuli is far more rewarding than continuing to invest attention and interest in external reality. In my experience, these are the essential dynamics in most cases where a diagnosis of schizophrenia has been assigned.
Now, of course, it’s possible for hallucinations to occur because of neurological impairment. Such impairment can be temporary (e.g. morphine induced) or permanent. But it is never safe to assume a neurological impairment on the basis of a behavioral problem. The behavioral explanation outlined above is more parsimonious and far more likely to be correct.