“What he hears is normal, it’s his fear”

  • ‘Hearing voices’ can occur in asylum seekers.
  • The voices may arise from traumas they suffered in the country they fled.
  • They may also arise from fears caused by the asylum system in the country they seek refuge in.
  • What the voices say can make sense, given what the person is going through.
  • Safety and community are central to mental health.

Asylum seekers on the Greek-Macedonian border

“Fear” writes Veronica Roth in Divergent, “doesn’t shut you down; it wakes you up”.†

But it may also awaken others within you.

I say this in the context of having just read a report on the effects of the asylum procedure on asylum seekers’ mental health.

The authors are clear that prolonged legal insecurity, the obligation to move from one center to another, and isolation, among other factors, contribute to mental health deterioration.

Trauma and hearing voices

It is well known that many refugees suffer post-traumatic stress disorder (PTSD) as a result of traumas they experienced in the country from which they fled. This often includes ‘hearing voices’.

For example, a Danish study found 17% of refugees with PTSD, most of whom had experienced torture and imprisonment, heard voices. Such findings have previously led me to argue that hearing voices should be recognised as a potential symptom of PTSD.

We tend to focus on the potential for voice-hearing to arise from events that happened in the country from which the person is fleeing . Yet this should not obscure a potential role for events that happen to them in the country to which they flee.

Take, for example, this quote from a paper by Richard Bentall and Charles Fernyhough:

“Incidence rates [of psychosis] are greatest in those immigrants who are living in neighborhoods in which they form a clear minority, suggesting that discrimination, experiences of social defeat and powerlessness, and/or lack of social support may be important in conferring risk of illness.”

Indeed, the report I just read highlights that the stresses of the asylum seeking process in the ostensibly safe country a person flees to, may also lead to hearing voices.

What is also notable about this report is that they quote a psychologist describing voice-hearing in this context as a normal reaction to a frightening situation. This portrays hearing voices not as a sign of madness, but a manifestation of fear.

In the report, this happens in the case of Dilraj.

Dilraj’s story

Dilraj was a 30-year-old Indian asylum seeker referred to a center for victims of torture in Greece. His doctor said he had “a clear case of post-traumatic stress disorder.” Dilraj was living alone in hotel room in an old building used to house asylum seekers.

He felt socially isolated and was scared to leave his home as he didn’t know many other members of the Sikh community. Due to personal financial reasons, he was forced to move out of his small hotel room.

Put into shared accommodation, he accused his roommate from Pakistan of spying on him. Voices and paranoia began, and he was hospitalized as a result.

Many of the voices he heard were those of authority figures, including officials in Greece. The authors note that Dilraj seemed to be as scared of the Greek authorities as he was of the people who tortured him in his country of origin. He was unsure of whether or not asylum would be granted to him, and this made him even more afraid.

Given his situation, it is not a puzzle why the voices said what they did. One voice said: “You will be homeless you will be homeless.” Another said: “They will not believe you, they will send you back to India.”

His psychologist stated “What he hears is normal, it’s his fear

Safety and mental health

This situation is unlikely to be limited to PTSD. People with other diagnoses, such as schizophrenia and borderline personality disorder (and even some with no psychiatric diagnosis), may also have their voices rooted in their fears.

Indeed, the hypervigilance theory of voice-hearing  proposes that some people’s voice-hearing may be rooted in the way our threat-detection system evolved to work.

For example, imagine you are in the woods and hear a twig snap behind you. You may panic and think it is a bear. If you turn out to be mistaken (a ‘false positive’), you may feel a bit foolish as a result. But if you had just carried on walking, assuming it wasn’t a bear, when it actually was (a ‘false negative’), then the cost of your mistake would be much greater.

Evolution is prejudiced – it favours those who don’t get eaten – and as a result  we have a threat detection system that is going to result in a lot of false positives. The hypervigilance theory of voice-hearing proposes this contribute to people’s tendency to hear threatening voices even when they are not actually there.

More generally, we may ask how many people’s mental health could be facilitated simply by making them feel safer?

Many, it would appear. Indeed, perceived safety has often been linked to mental health, such as in the manner below (taken from this paper):

 

However, as usual, the answer may not be as straightforward as one imagines. One study (referenced here, but which I can’t track down) reported that people suffering from psychosis who lived in areas with high perceived community safety actually had higher hospital readmission rates. This was proposed to be because of low community tolerance of unusual behaviour.

Nevertheless, it is clear that Dilraj’s experiences of the asylum system in Greece had a negative effect on his mental health.

Dilraj sought safety and was given fear.

Society needs to do better.


End notes

You can read the report at: http://nccr-onthemove.ch/highlights-2/highlights-2-5-2/

† Of course, in reality, there are a range of responses to fear – see here for more.

I give a fuller discussion of ‘hearing voices’, as well as their links with trauma, in my book “Can’t You Hear Them? The Science and Significance of Hearing Voices

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Taking back the brain: Trialling neurofeedback for voice-hearing

Hearing voices (also referred to as ‘auditory verbal hallucinations’) need not be associated with problems. However, for a number of people, they are. Problems are particularly likely to arise if the voices are frequent, say negative things, and if the person has no control over them.

Different people want differ ways to cope with their voices, as our research has previously found. For some, medication may be the solution. For others, approaches such as cognitive behavioural therapy or the Hearing Voices Movement’s Maastricht Interview may provide answers and peace.

Another potential way of coping is neurofeedback.

Neurofeedback works by showing people their brain activity in real-time, and then training them to manipulate this. It allows you to control your own brain.

I have just received some funding from the US-based Brain & Behaviour Research Foundation to test whether EEG-based neurofeedback can help people distressed by voice-hearing. My thanks go to them and to their donors for making this research possible.

The trial will be done in collaboration with Dr Michael Keane at the Dublin-based neurofeedback clinic, Actualise.

Work will start towards the end of 2017, when I will be looking to recruit a post-doc to work on this trial with me.

Hopefully this approach will prove effective and give people who are distressed by their voices another therapeutic option to choose from.

More soon.

SMJ

50-to-life: Why the phenomenology of ‘hearing voices’ matters

Joan of Arc at Trial

Interrogation of Joan of Arc (Delaroche)

The experience of “hearing voices” has been reported for millennia, including by people such as Socrates, Joan of Arc, and the Beach Boy’s Brian Wilson.

It can be experienced in the context of a diagnosed psychiatric disorder (e.g., schizophrenia, borderline personality disorder, PTSD, anorexia), a neurological disorder, or by people without any diagnosis who may highly value these companions.

The study of what these voices are like (formally termed their ‘phenomenology’) can give clues as to what may cause them and inform the development of ways to help people distressed by them.

An accurate knowledge of the phenomenology of hearing voices can also be of great importance for other reasons, one of which involves the law.

The case I will describe here to illustrate this point was discussed in a recent paper I co-authored with the forensic psychiatrist, Dr Phillip J. Resnick. He has previously provided consultation in many high profile legal cases including those of the serial killer Jeffrey Dahmer, the Oklahoma City bomber Timothy McVeigh, Theodore Kaczynski aka the Unabomber, and Andrea Yates. Our paper examined how knowing what hearing voices is like can help to determine whether people are faking the experience for perceived gain (formally termed ‘malingering’).

As part of this we examined the role of the phenomenology of hearing voices in the case of Senque Jefferson who, in 2004, came before the Court of Appeals of California, Third District, to appeal against a verdict he had received in a trial two years earlier; a verdict which, per the ‘three strikes law’, resulted in him being sentenced to ‘50 years to life’.

To be clear from the outset, neither that paper nor this blog aimed to give an opinion as to the veracity of the claims of the Defendant in this specific case. Instead they simply aim to show the importance of an accurate knowledge of the phenomenology of hearing voices in relation to a situation where a Defendant claims to have been having such experiences at the time of a crime.

Let’s begin with a bit of background.

 

The background

In 1994 Senque Jefferson was incarcerated in California as a result of being convicted of first degree murder and a series of armed robberies.

Approximately six years later, on the 10th March 2000, he was to be found in the psychiatric services unit of New Folsom Prison in California.

That morning, Jefferson was being escorted back from the exercise yard by two prison officers. As he was about to be put back into his cell he kicked one officer in the stomach, and the other in the leg. Jefferson was in turn then punched by one of the officers, after which Jefferson spat on both. This led Jefferson to be charged with, and ultimately convicted on, two counts of battery.

Later that same year, on the 3rd July, Jefferson was in the infirmary of Sacramento jail, where inmates experiencing a mental health crisis were housed. He was taken to a holding cell ahead of a meeting with a committee of mental health professionals to review his placement in the infirmary. Eventually the committee decided it would not see him that day, and ordered him to be taken back to his cell in the infirmary. As he was being taken out of the holding cell, Jefferson kicked one of the prison officers twice in the leg. This act formed the third count of battery upon which he was charged and later convicted on. Under the “Three Strikes Law” he was sentenced to ‘50 years to life’.

 

The defence

Why did Jefferson say he did these acts? In relation to the first incident in March, the court documents tell us that his lawyers argued that:

“As the officers placed him in his cell, [the] defendant heard “voices” outside his head. The voices told him the officers would hurt or kill him when he was in his cell, so he kicked the officers to get them off him”

In relation to the second incident in July, his lawyers stated that:

“the voices became loud while he waited in the holding cell, telling him not to leave the cell because the officers would hurt him”

More generally, his lawyers claimed that Jefferson:

“heard voices ‘everyday, all day’…The voices were usually those of women he knew when he was out on the street. They told him such things as his food was poisoned or a family member had died. At the time of trial, he was on medication — involuntarily — that he felt lowered the voices. Although the voices were powerful, he was able to ignore them better.”

 

Phenomenology and the prosecution

The first part of Jefferson’s trial, termed the ‘sanity phase’, involved establishing whether he was sane or insane. Here, Jefferson’s argument that he was hearing voices came under scrutiny. One of the court-appointed psychologists met with Jefferson and asked him to describe the voices he heard in order to “determine whether [the] defendant was faking a psychological problem”. During this Jefferson stated that his voices “were voices of ‘people that he knew in the past’ and were ‘in his ear’”.

This is where phenomenology has direct application. The court-appointed psychologist attempted to compare the location and nature of the voices Jefferson described against what they thought was the typical phenomenology of the experience. The court documents describe how, in the court-appointed psychologist’s experience:

“schizophrenics typically described voices ‘as coming from inside their head and being of either famous people or strangers or groups of people.’ She [the court-appointed psychologist] thus doubted defendant’s claims.”

But does the research literature support the court-appointed psychologist’s description of the phenomenology of hearing voices in people diagnosed with schizophrenia? Let us look at the specific issues raised by the court-appointed psychologist in turn.

 

Assertion 1: Voices are typically heard as coming from inside the head

The largest study of the phenomenology of ‘hearing voices’, published by myself and colleagues in Melbourne (McCarthy-Jones et al., 2014b), interviewed 199 patients who heard voices (81% who had been diagnosed with schizophrenia) and found that 38% heard both voices coming from inside and outside their head, 34% only heard internally-located voices, and 28% only heard externally located voices.

nd-96

Nayani & David’s (1996) findings

The largest study before ours was performed by Nayani and David (1996) who examined the phenomenology of the voices heard by 100 psychiatric patients (the majority who had a diagnosis of schizophrenia).

You can see their findings pertaining to the location of patient’s voices in the table on the right.

They found that only 38% of patients described their voices as having a voice which was located inside their head, whereas 49% of the sample “heard their voices through their ears as external stimuli”.

 

Since both these studies, a study in 2015 by Angela Woods and colleagues, of 125 people who heard voices people (with a range of, or no, diagnoses), found that “Voices with a physical location were equally likely to be external or internal”.

Clearly, a substantial number of people (with or without a diagnosis of schizophrenia) hear voices that are not located inside their head. 

This variability has led Resnick and Knoll (2008) to argue that the “location of hallucinations should not be used to determine their genuineness”.

 

Assertion 2: Voices are typically those of famous people or of groups of people or those of strangers.

Formal studies reporting on the number of people diagnosed with schizophrenia who identify their voices as being those of famous people are few in number and small in sample. For example, Leudar et al. (1997) found that 6 of 13 people diagnosed with schizophrenia said that their voices were those of public figures.

Larger studies suggest that voices are likely to be of people personally known to the hearer.

For example, Nayani and David (1996) found that “Hallucinated voices were often known to the patient in real life, indicating that they may be modelled on the memory of a real voice.” In their study 46% of patients heard voices which could be identified as likely being real, known people, such as a relative, neighbour, or doctor.

Similarly, Garrett and Silva (2003) found that 46% of patients (the majority of whom had a diagnosis of schizophrenia) “believed they recognized at least one of their voices as a specific friend, family member, or acquaintance”.

My colleagues in Melbourne and I found that 70% of patients reported that the voices they head were like those of people who had spoken to them in the past (McCarthy-Jones et al., 2014b).

The wider voice-hearing literature is also replete with examples of people hearing voices of people they personally know and have actually encountered in the past (e.g., Romme et al., 2009).

In terms of groups of voices, although Nayani and David found 57% of patients described hearing the sounds of crowds of people mumbling or talking together (in addition to individualised voices), we (McCarthy-Jones et al., 2014b) found that 53% of patients had never heard all their voices speak at the same time (like a chorus).

 

Conclusion

Doubt was cast on Jefferson’s voice-hearing experiences because they did not resemble a characterisation of voices as typically “coming from inside their head and being of either famous people or strangers or groups of people”. I would argue this is a flawed yardstick against which to measure people’s voice-hearing experiences, given the research reviewed above.

By noting this, I am not offering an opinion as to whether or not Jefferson was actually hearing voices (this cannot be determined from a review of court documents) I am simply noting that the stated phenomenology of voice-hearing used in the courtroom appears flawed.

This is just one way in which phenomenology could be used in the court room in relation to voice-hearing. For example, it could have been asked whether or not the changes Jefferson reported to the phenomenology of his voice-hearing experience after taking antipsychotic medication was consistent with the typical experience of patients.

Recall that Jefferson claimed that the:

“medication… he felt lowered the voices. Although the voices were powerful, he was able to ignore them better”

Now, consider one of the earliest reports of how antipsychotics affected the phenomenology of patients’ voice-hearing experience. A 1954 study by Elkes and Elkes found that chlorpromazine did not make voices disappear, but only made patients less bothered by them. Patients didn’t shout and scream at their voices as much. One patient stated that his voices ‘did not worry him so much’

Or take a more recent example from a statement by the respected Shitij Kapur and colleagues (2005) who explain:

“Antipsychotics do not eradicate symptoms, but create a state of detachment from them… it is widely known that for most patients antipsychotics provide only partial remission – and many aspects of psychosis as well as other aspects of the illness remain untouched. While some patients do actually achieve complete resolution of their delusions and hallucinations with antipsychotic treatment, for many patients a detachment from their symptoms is as good a resolution as antipsychotics can provide.”

It is hence clear that in situations such as that described above, a correct knowledge of the phenomenology of ‘hearing voices’ may be of paramount importance. Furthermore, dependent on the circumstances in which it is applied, it may even be a matter of life and death.

 

References and further resources

Appeal document referred to here:

References

Elkes, J. et al. (1954). Effects of chlorpromazine on the behaviour of chronically overactive psychotic patients. British Medical Journal, 2, 560–76.

Garrett, M., & Silva, R. (2003). Auditory hallucinations, source monitoring, and the belief that “voices” are real. Schizophrenia Bulletin, 29(3), 445-457.

Kapur, S. et al. (2005). From dopamine to salience to psychosis – linking biology, pharmacology and phenomenology of psychosis. Schizophrenia Research, 79(1), 59–68.

Leudar, I., Thomas, P., McNally, D., & Glinski, A. (1997). What voices can do with words: pragmatics of verbal hallucinations. Psychological Medicine, 27(04), 885-898.

McCarthy-Jones, S., & Resnick, P. J. (2014a). Listening to voices: the use of phenomenology to differentiate malingered from genuine auditory verbal hallucinations. International Journal of Law and Psychiatry, 37(2), 183-189.

McCarthy-Jones, S., Trauer, T., Mackinnon, A., Sims, E., Thomas, N., & Copolov, D. L. (2014b). A new phenomenological survey of auditory hallucinations: evidence for subtypes and implications for theory and practice. Schizophrenia Bulletin, 40(1), 231-235.

Nayani, T. H., & David, A. S. (1996). The auditory hallucination: a phenomenological survey. Psychological Medicine, 26(01), 177-189.

Resnick, P. J., & Knoll, J. L. (2008). Malingered psychosis. In R. Rogers (Ed.), Clinical assessment of malingering and deception (pp. 51–68). New York, NY: Guilford Press.

Romme, M., Escher, S., Dillon, J., & Corstens, D. (2009). Living with voices. 50 stories of recovery. Ross-on-Wye: PCCS Books.

Woods, A., Jones, N., Alderson-Day, B., Callard, F., & Fernyhough, C. (2015). Experiences of hearing voices: analysis of a novel phenomenological survey. The Lancet Psychiatry, 2(4), 323-331.

Further resources on hearing voices

Schizophrenia is not a mental disorder?

There has been a lot of debate over the past decades about the reliability and validity of the diagnosis of schizophrenia. There has been the Campaign for the Abolition of the Schizophrenia Label, books such as Schizophrenia: A Scientific Delusion?, and most recently a 2016 paper in the British Medical Journal with a very unambiguous title:

van-os

Despite such arguments, these authors typically only call for schizophrenia to be renamed, as happened in Japan recently. And what it is renamed as will still be classified as a mental disorder.

This is why the recent reports that the Pakistan Supreme Court had ruled that “schizophrenia is not a mental disorder” came somewhat out of left-field.

news-reports

What is happening here?

Are the views of the Pakistan Supreme Court being misreported? If so, what did they actually say?

Or, if this is what the Court said, how did they reach this decision?

It is a simple matter to access the actual judgement to find out, which is what we will try to do here.

 

The background

In 2002 Imdad Ali (pictured below, as held by his wife) was convicted of killing a religious teacher. He received the death sentence (I have not been able to access any court records pertaining to this original trial).

image-22-10-16

On 21 October 2016 the Supreme Court of Pakistan turned down a plea to delay his execution (by hanging). Extracting the court’s reasoning from media reports, we can piece together the following:

  1. The Supreme Court said schizophrenia was an “imbalance”, exacerbated by stress, that could be treated by drugs.

Whilst one could argue with this, it is consistent with mainstream views, such as that of the US National Institute for Mental Health (see below) who publicly endorse the chemical imbalance idea.

nimh-website

2. The Supreme Court therefore determined that schizophrenia is “not a permanent mental disorder”

Recovery from schizophrenia happens, so this too is not necessarily a controversial statement. That said, it is worth noting the grim results of a recent review that found only one in seven people diagnosed with schizophrenia was achieving a comprehensive recovery and that recovery rates had not improved over time.

3. The Supreme Court hence concluded that it must be “a recoverable disease, which… does not fall within the definition of ‘mental disorder”.

As we noted above, schizophrenia clearly is something that people can recover from, but the issue is how we then get to the idea that it is not a mental disorder. The reasoning behind this is somewhat opaque in media reports. This lack of clarity understandably led to this claim being met by a public outcry.

 

The reaction

This story was met by widespread disbelief. But not disbelief of the veracity of the story, but rather by disbelief that anyone could say that schizophrenia was not a mental disorder.

In a Press Release, a Director of the UK human rights organisation Reprieve commented that:

“It is outrageous for Pakistan’s Supreme Court to claim that schizophrenia is not a mental illness, and flies in the face of accepted medical knowledge, including Pakistan’s own mental health laws. It is terrifying to think that a mentally ill man like Imdad Ali could now hang because judges are pretending that schizophrenia is not a serious condition.”

Professionals were brought out to state that schizophrenia was a mental illness. The President of the Pakistan Psychiatric Society, Dr Sultan, said:

“It is a serious disorder which affects how a person thinks, feels and acts. Someone with schizophrenia may have difficulty distinguishing between what is real and what is imaginary; he or she may be unresponsive or withdrawn; and may have difficulty expressing normal emotions in social situations. In its most chronic form, schizophrenia can a life-long disease in which the patient does not feel normally or react like normal people”

It was shown that the public also thought that schizophrenia was a mental disorder. For example, The Express Tribune in Pakistan did a reader poll:

express-tribune-poll

No-one seems to have considered the alternative response; “is that really what the court said?” So let’s now back up a bit.

What did the court actually conclude, and how did it reach this conclusion?

 

What the Supreme Court judgement actually said

  1. The Supreme Court starts by stating the grounds of the appeal.

The basis of the appeal, made by Imdad’s wife, was that Imdad had schizophrenia and therefore needed medical treatment so that he could make a will before he was executed.

2. The Supreme Court reviews previous courts’ rulings

The Supreme Court states that Imdad’s claim he had schizophrenia (or as the Court puts it, that he was a ‘lunatic’) had been satisfactorily addressed by all previous courts and was hence not grounds for appeal.

previous-consideration

Later in the judgement the court makes clearer that Imdad had previously argued that he had schizophrenia, but the lower courts had discarded this.

paranoid-sz

The Supreme Court then argues that, even if Imdad did have schizophrenia, by Prison Rules officials should have noted this and taken appropriate steps, but they didn’t.

We may have expected that, having deemed that previous courts had addressed the schizophrenia issue, the Supreme Court would have wrapped up its judgement there and then.

But, oddly, it didn’t.

Instead, the Supreme Court next spent a long time giving its own view as to why schizophrenia is not always schizophrenia. It is initially unclear why it felt the need to take this on.

3. The Supreme Court comes to the conclusion that someone with a psychiatric diagnosis of schizophrenia doesn’t always meet the legal criteria for mental disorder.

Here we come to the crux of the transcript in relation to the media headlines. It turns out the court is not denying that schizophrenia is a severe mental disorder (indeed, they cite such a definition in their judgement). Instead they state that someone with a psychiatric diagnosis of schizophrenia does not always meet the legal criteria for having a mental disorder.

Here’s the relevant excerpt from the court’s judgement. The key phrase is ‘in all the cases’:

not-sz

Let’s now work through how the court arrived at this judgement.

It drew on (old) arguments from American psychiatrists and previous case-law.

Their first move was to cite an American psychiatric textbook saying there are degrees of schizophrenia. Here the court cites the following  (quite why they use a textbook from 1966 is unclear);

degrees-of-schizophrenia

The second move is to cite from the same textbook that recovery is possible:

recovery

The third move is to say that each case of schizophrenia needs to be considered on its own merits. Here they cite precedent and the famous American psychiatrist Karl Menninger (1893-1990):

menninger

The Court has now reached the point where it has established that merely saying someone has schizophrenia does not necessarily prove anything about the person. To ram this home it goes on to give an example of a case when simply having a diagnosis of schizophrenia was not deemed in and of itself to be indicative of anything. In said case, a husband applied for a dissolution of marriage on the basis that his wife had a diagnosis of schizophrenia and was therefore “unfit for married life”. This previous case concluded as follows:

schizophrenia-is

Schizophrenia is what schizophrenia does? An interesting idea. What are the implications of such a statement though?

Anyway, given all this, the Court can now reach its conclusion, in relation to schizophrenia, which to reiterate, was:

not-sz

Two things puzzle me here.

The first is why they took this route to reach their conclusion. The latest version of Psychiatry’s Bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) explicitly states that just because someone has a diagnosis of a mental disorder, this doesn’t mean they will necessarily meet the legal criteria for a mental disorder. Here is the relevant except from the DSM-V:

dsm-v-mental-disorder

I don’t see why the Court couldn’t have just referred to this.

The second thing that puzzles me is why the Court is even concerned to make this point.

The question is surely not whether or not someone with a diagnosis of schizophrenia always meets legal criteria for mental disorder, but rather whether Imdad specifically met the legal criteria for mental disorder.

As far as I can see, the Court seems to be trying to find if there was a way that earlier courts could have reached the seemingly paradoxical conclusion that Imdad had schizophrenia but that this wasn’t a barrier to his execution. Yet, whether this was how earlier courts came to their conclusions is unclear, and more importantly, whether or not Imdad meets/met diagnostic criteria for schizophrenia is not clearly established.

 

The final judgement

The court then sums up its final decision, and its reason for rejecting the appeal, as follows:

court-ruling

This is also confusing to me.

If, as the Court states, rules relating to mental illness can’t delay an execution, then why has so much of their judgement been spent trying to find a way to argue that schizophrenia isn’t always schizophrenia?

 

Post-judgement reaction

That it urgently needs determining whether or not Imdad meets the diagnostic criteria for schizophrenia, and if this meets the legal definition of mental disorder in his case, now seems to have been recognised by the Court.

On 31 October 2016, the Supreme Court postponed Imdad’s execution after a fresh petition from his lawyers, and a review petition from the government of Punjab province (where he is held). This latter petition claimed the Supreme Court’s definition of schizophrenia had “resulted in a grave miscarriage of justice”, because it was contrary to the universally accepted medical definition of ‘mental disorder’ and alleges that prison medical records show Mr Ali has “consistently displayed symptoms of schizophrenia” and “is not showing signs of improvement and has active psychotic symptoms”. http://www.ekklesia.co.uk/node/23565).

On 14 November 2016 the Supreme Court ordered a panel of doctors to examine Imdad’s mental health (http://www.ekklesia.co.uk/node/23580)

On the 18 November 2016 the Supreme Court said that if psychiatrists find Imdad is mentally ill, his execution will be delayed until recovery (http://www.ekklesia.co.uk/node/23580)

It seems likely that he will be deemed to have schizophrenia.

Imdad’s sister describes that their father had schizophrenia. When Imdad was just two years old, his father died after jumping in front of a train because he thought he was invincible. He left a widow and six children.

The genesis of Imdad’s own mental health problems are also described by his sister:

sister-describes-what-happened

Furthermore, Reuters reports that Government doctors in 2012 certified Imdad as having paranoid schizophrenia. For example, it cites a Dr Tahir Feroze, a government psychiatrist who has treated Ali for the last eight years of his incarceration, who says he and two other doctors certified Ali’s condition in 2012. Imdad suffers from delusions that he controls the world, is persecuted and he hears voices in his head that command him, according to Dr Feroze and Imdad’s wife. Yet Imdad’s lawyer says the government report certifying his condition had never been presented in court before 2016.

 

Conclusions

Bearing in mind a number of caveats (I am not a lawyer, I have limited access to information to this case, and so this is just a lay-reading of what is going on), here are my own take-aways from all this.

1. The Supreme Court was saying someone diagnosed with schizophrenia may not meet the legal definition of mental disorder. They were not saying that schizophrenia is not a mental disorder in the psychiatric sense.

There is nothing controversial about this, although the Court did reach this conclusion in something of an idiosyncratic way. If reporters had read the freely available court documents, this misunderstanding would not have arisen.

2. Progressive arguments may have regressive effects.

It is notable that the court drew on a lot of progressive arguments, such as the potential for recovery from schizophrenia, and that schizophrenia does not a priori define a person, in order to make the case that Imdad should die. We should be aware that progressive arguments, which humanise and empower people diagnosed with schizophrenia, also run the risk of misrepresenting people’s degree of agency and may end up blaming them for things they were not responsible for. We need a discussion of the relation between mental illness and criminal responsibility that acknowledges shades of grey.

3. It is unclear why the Supreme Court undertook a consideration of what schizophrenia is.

This seems to have been irrelevant to the actual basis of their judgement.

4. It is unclear why a consideration of the relation between schizophrenia and legal definitions of mental disorder was undertaken which did not then go on to consider this in relation to Imdad specifically.

Although the Court has now allowed that if Imdad is deemed to have schizophrenia then his execution can be delayed until he has recovered, little is being mentioned about whether Imdad was suffering from a mental disorder (in the legal sense) when he killed the religious teacher. If so, this could commute the death sentence, rather than just delay it. An independent and authoritative assessment of Imdad’s current and historical mental health state clearly needs to be made.

5. If Imdad had schizophrenia at the time of his offence, or has it now, international law says he should not be executed.

As Amnesty International note, citing the examples below, the execution of someone with a mental illness is clearly prohibited by international law:

International Resolutions Year Excerpt
UN Safeguards Guaranteeing Protection of the Rights of Those Facing the Death Penalty 1984 ” …nor shall the death sentence be carried out… on persons who have become insane.”
UN Special Rapporteur on Extrajudicial, Summary or Arbitrary Executions 1997 Governments that continue to use the death penalty “with respect to minors and the mentally ill are particularly called upon to bring their domestic legislation into conformity with international legal standards.”
UN Commission on Human Rights 2000 Urges all states that maintain the death penalty “not to impose it on a person suffering from any form of mental disorder; not to execute any such person.”

 

Media reporting of this story typically went for sensationalist headlines that did not convey that the Court was uncontroversially saying that someone with a diagnosis of schizophrenia may nevertheless fail to meet the legal definition of mental disorder.

Yet there are clearly many other problems with this case, and the media spotlight has engendered a passionate response from public and human rights bodies who have put pressure on the Pakistan Supreme Court to rectify a genuine problem, namely that Imdad’s mental health does not seem to have been fully assessed, addressed, and taken into account. This response has very plausibly extended Imdad’s life and may even contribute to saving it.

At the time of writing, 31,000 people have signed a petition calling for Imdad to be saved.

I will update the blog for what happens next.

 

Silence of the Ancients

I’d found a Narnian door for adults…

assyrian-sectionIt led from a ordered, public gallery in the British Museum to a sprawling and private unseen back-world of crates, dust and straw. Here, history peeped out one corner at a time and raging mummies rampaged freely. Well, maybe not the mummies. As I crossed the threshold, I felt as if I was encountering real history. These were not explicated exhibits safe for consumption, but representatives of a fragmented, unclassified and perhaps unclassifiable past. I walked meters but travelled millennia, back to Sumer, Babylon and Assyria.

finkel

Dr Irving Finkel

Dr Irving Finkel was my guide, the British Museum’s Assistant Keeper of Ancient Mesopotamian script, languages and cultures. Finkel is a cross between Harry Potter and Professor Dumbledore. His huge, tumbling white beard spews tirelessly downwards, a boyish twinkle lurks in his bespectacled eyes, and a PhD in Ancient Mesopotamian Exorcistic Magic sits in his back pocket. I felt like Ron.

mammothI had come to visit Dr Finkel to find out if voice-hearing was present in the earliest written records we possess. Although spoken language is thought to have begun around 50,000 years ago, no-one got around to writing anything down for the next 45,000 years.

Whilst this could have been due to arguments over how words like ‘cognac’ should be spelt, the consensus is that there was a mammoth stationary problem (a lack of materials to write on, not mammoths eating all the pens).

It was only around 3,000BCE that the Sumerians discovered writing on clay and then baking it produced texts which stood the test of time, despite (or perhaps due to) being largely inedible.

Theirs was a world where ghosts (spirits of the dead) and demons were real. A person’s spirit (Sumerian = “gidim”, Akkadian = “etemmu”) was believed to separate from their body at death, being potentially visible and audible. There are accounts of these spirits returning to persecute the living, entering through their ears. Nevertheless, after talking with Dr Finkel, and later with other Mesopotamian scholars around the world, specific examples of voice-hearing remained elusive. Only whispers reach us, and the telephone line from the past crackles with distortion.

In 1965 Kinnier Wilson claimed to have identified a voice-hearing experience in the Maqlu series of tablets, which discuss witchcraft. In a discussion of witches’ persecutors, Kinnier Wilson argues that one of them, a bel egirri was “probably not seen at all, being doubtless that “voice” which may issue short commands or comments, sometimes feared, sometimes respected, in auditory hallucinations”. Yet the noun ‘bel’ literally means owner of a certain characteristic or property, and the compound bel egirri can be translated broadly as a slanderer who gives you a negative reputation. A bel-egirri is a Lord of Slander, if you will. Yet it is unclear whether this refers to a hallucinated voice or a real person who is acting in a persecutory manner. Dr Finkel suggests to me that it is likely that these are not auditory hallucinations.

We could claim a potential account of voice-hearing in a story involving a Babylonian demon called “the croucher”, who had the face or form of a goat. However, any sentence starting “Babylonian goat demons teach us…” is going to be a hard sell, not helped by images coming to mind of Dan Ackroyd and Tom Hanks doing the goat dance in the film Dragnet.

Another possibility is that what ancient physicians referred to as “confusion of self”, in which a patient “can see the illness that afflicts him, he talks with it and continually changes his self” may refer to voice-hearing. But we are stretching here. Instead of voices being the means of contacting the divine, in Ancient Mesopotamian civilisations dreams were the primary method of contact with the gods.

Egyptologists have not uncovered clear evidence of voice-hearing in Ancient Egyptian papyri either. This is strange, as Ancient Egyptian cosmology was perfectly configured to allow such experiences. As the Egyptologist Kasia Szpakowska (2009), who leads a fascinating Ancient Egyptian Demonology Project, describes, in Ancient Egypt the afterlife was populated by anonymous hordes of demons and deputised demons of darkness, the unjustified dead and the damned, hostile transfigured spirits, passers-by and messengers, as well as the gods. All were thought able to step through the permeable membrane between our two worlds and attack, causing both physical disease and emotional problems. Egyptians could fight back using spells, ritual actions, as well as substances such as garlic, beer, and spit. If garlic beer spit didn’t work, and one trembles to think what entity could withstand that combination, then Egyptians could resort to using the gall-bladder of a tortoise.

Not all inter-world communication was negative. Contact with the dead, achieved through dreams, which sleeping in certain temples was thought to facilitate, was used to help restore mental balance. The closest we get to voice-hearing is in a medical papyrus (Ebers Papyrus, ~1,550BC) that addresses ‘mental illness’ in a section on disease of the heart, an organ which the Egyptians viewed as doing the things which today we ascribe to the brain. A passage here refers to an experience in which a person’s “mind raves through something entering from above”. Again though, this is hardly convincing as an illustration of voice-hearing. As in Ancient Mesopotamia, dreams were the main way in which the divine was communicated with in Ancient Egypt.

ezekielIt is unclear why we can’t find voice-hearing at this early time. Was this experience genuinely not occurring at this time? Or is it just that we can’t find records? What is strange is that in the Hebrew Scriptures we have records of Ezekiel living in Babylon and hearing voices, and Moses hearing voices in the context of Ancient Egypt. Why are these experiences reported by early Jewish prophets living in these societies, but not in the writings of the societies themselves?

At present the answer is not at all clear. Such is history. There is an elephant in this ancient uncertainty though, and his name is Julian Jaynes.

jaynesIf Philip K. Dick thinks your work is stunning, you can take that to your headstone. One recipient of such praise was Julian Jaynes, whom Dick wrote to. In 1976 Jaynes published The Origin of Consciousness in the Breakdown of the Bicameral Mind, a book which Richard Dawkins (2007) has argued to be one of those books that is either complete rubbish or a work of consummate genius, nothing in between.

 

Jaynes argued that in the bicameral period, a term which he uses to refer to the period between 9,000–1,000BC, all humans automatically heard voices when they were faced by any tricky decision. This was because, claimed Jaynes, the brain is bicameral (literally ‘two-chambered’), with the left hemisphere involved in normal human speech production “the language of man” (sic) and the right hemisphere producing “the language of the gods”. Jaynes proposed that, in the bicameral period, speech was generated in the right hemisphere of the brain, and then passed across to the auditory areas of the left hemisphere and that, experientially, this resulted in people hearing the voice of ‘a god’ telling them what to do. He then claimed that in around 1400BCE in Ancient Mesopotamia, this bicameral mind broke down, for reasons such as writing replacing the oral/auditory mode of command giving. Self-consciousness then arose and the voices of the gods were replaced by the inner speech we all have today.

Some people who hear voices have found this interpretation of their experiences helpful and liberating; they are having an experience that was once entirely normal and have a link with a noble historical lineage. Utility is not my primary concern here though, and back in 2012, in my book Hearing Voices, I tried to establish if there is any truth in Jaynes’ theory.

One of Jaynes’ arguments is that characters in the Iliad (~1230 BCE) such as Agamemnon and Achilles, do not have conscious thoughts and that there is no word used in this text for consciousness. Instead characters’ actions begin “not in conscious plans, reasons, and motives… [but in] the actions and speeches of gods”. He goes on to argue that “voices whose speech and directions could be as distinctly heard by the Iliadic heroes as voices are heard by certain epileptic and schizophrenic [sic] patients, or just as Joan of Arc heard her voices”. One of the snappiest arguments against this comes from Richard Bentall who tells the story of a trip to a country where a philosopher informed him that in the local language they had no words for ‘he’ and ‘she’. The people of the country though, the philosopher noted, certainly knew the difference.

Another poetry-based argument of Jaynes’ is derived from the lines of the Mesopotamian poem Ludlul Bel Nemeqi (Poem of the Righteous Sufferer) which run, “My god has forsaken me and disappeared, My goddess has failed me and keeps at a distance, The good angel who walked beside me has departed”. Jaynes argues this supports his thesis that the gods vanished, leaving people with just their own inner speech. For me though, this is like someone from the year 3,000 (click on the link at your peril) claiming the lines “I wandered lonely as a cloud” as evidence for their theory that the first jetpack was invented back in 1804 by Wordsworth.

alterIf poetry doesn’t convince you, perhaps sculpture will. Jaynes shows us a carving of a stone alter made about 1230BC made for the king of Assyria, Tukulti-Ninurta I. In this, Jaynes claims that the king is kneeling before an empty throne, where normally in previous carvings a god would have been shown. As Jaynes puts it “No scene before in history ever indicates an absent god. The bicameral mind had broken down”. However, as I have been informed, it appears that this throne is in fact an altar. And the altar isn’t empty. It has on it what is either a clay tablet with a stylus, or a hinged writing board; likely a symbol of Nabu, the god of writing. As I have discussed elsewhere, other arguments-from-sculpture of Jaynes similarly fail to hold water. Indeed, it is a simple matter to ask experts on Ancient Mesopotamia their opinion, and when you do, you hear back that there is no evidence that people routinely heard the voices of the gods.

We are hence left with an ancient uncertainty. Was there voice-hearing in Ancient Mesopotamia and Egypt, outside of the Hebrew Prophets? If not, why not?

Today we can understand many experiences of voice-hearing as being reactions following traumatic life events. We already know that the form that post-traumatic reactions take is affected by culture. For example, as Watters (2010) has noted, shell shock after WWI typically took the form of bodily symptoms (tics, body movements), whereas after the American Civil War it took the form of an aching in the left side of the chest and a feeling of a week heart-beat. Maybe there genuinely wasn’t much voice-hearing in Mesopotamia, and this was because reactions to trauma took different forms. Such arguments are built on sand though, which is probably appropriate enough.

sand

Lone, albeit not level, sands stretch far away

 

My new book Can’t You Hear Them? The Science and Significance of Hearing Voices will be available in April 2017.

 

 

 

Acknowledgements

Thanks to Irving Finkel and Jo Ann Scurlock for helping me understand the Ancient Mesopotamian period. This material is discussed in more depth in my previous book, Hearing Voices. McCarthy-Jones, S. (2012). Hearing voices: The Histories, Causes and Meanings of Auditory Verbal Hallucinations. Cambridge: Cambridge University Press.

 

References

Dawkins, R. (2007). The God Delusion. London: Transworld.

Jaynes, J. (2000). The origin of consciousness in the breakdown of the bicameral mind. New York, NY: Mariner Books.

Kinnier Wilson, J. V. (1965). An introduction to Babylonian Psychiatry. In Studies in honor of Benno Landsberger on his seventy-fifth birthday. Chicago, IL: University of Chicago Press (pp. 289–298).

Szpakowska, K. (2009). Demons in ancient Egypt. Religion Compass3(5), 799-805.

Watters, E. (2010). Crazy like us: The globalization of the American psyche. New York, NY: Free Press

Hallucinations and a brain wrinkle?

A recent study I was involved in, led by my colleagues at Cambridge University, found a relation between the length of a specific groove in the frontal lobe of the brain (formally termed the paracingulate sulcus, although dubbed a ‘brain wrinkle’ by the BBC) and the likelihood that a person diagnosed with schizophrenia will have experienced hallucinations.

You can discover more about the study through Cambridge University’s press release, through a summary by other members of the team based at Durham University, or through reading the paper itself. The reference and link are below.

Jane Garrison, Charles Fernyhough, Simon McCarthy-Jones, Mark Haggard, the Australian Schizophrenia Research Bank and Jon Simons, ‘Paracingulate sulcus morphology is associated with hallucinations in the human brain’, Nature Communications, November 2015.

Oh, and thanks to George Takei (Star Trek’s Mr. Sulu) for the mention:

 

 

How do antipsychotic drugs have their effect?

Today I’d like to draw your attention to a new paper just published by Moritz and colleagues (link here), which examines how antipsychotic drugs have their effect.

What did it do?

This on-line study involved 95 people, who had experience of taking antipsychotics, completing a questionnaire called the Effect of Antipsychotic Medication on Emotion and Cognition, which asked 49 questions about the subjective effects of antipsychotics. The participants had a range of psychiatric diagnoses, with 69 having a probable diagnosis of psychosis. They appear to have been mainly recruited through moderated German discussion forums for psychosis and other psychiatric disorders.

What did it find?

  • “patients strongly and rather consistently attributed a dampening of emotion,
    clouding of cognitive faculties and decreased joy to antipsychotic treatment”
  • “patients reported that antipsychotics decreased their emotionality, creativity and also exerted a detrimental effect on their cognitive faculties”
  • “Negative effects largely prevailed”
  • “patients reported that they were more doubtful due to antipsychotics”

[the measure of doubt included items such as mistrusting one’s own thinking, being indecisive about what is wrong, higher self-doubt]

  • “the majority of patients reported somewhat greater hard-headedness under antipsychotics”

[the authors explain their term ‘hard-headedness, by indicating that people predominantly endorsed the response option “narrow-minded and not open to other ideas”].”

  • “Doubt, numbing and withdrawal were the main subjective antipsychotic effects”

What do the authors conclude?

The authors conclude that “The induction of doubt and the dampening of emotion may be one reason why antipsychotics reduce positive symptoms” and note that their findings of reported antipsychotic effects including cognitive and emotional numbing, and social withdrawal are “disquieting”.

Limitations of the study

The authors note that the limitations of their study mean that they “have to refrain from bold conclusions”.

The first limitation was “that self-report assessments might be problematic in psychosis patients, as they have been consistently shown to lack metacognitive awareness”.

But this seems to suggest that people diagnosed with psychosis can’t be relied on to accurately report their experiences of antipsychotics being problematic, which is at best a questionable statement. Also, if a person said antipsychotics worked for them, would anyone question whether they were right on the basis that they may be saying this due to a lack of “metacognitive-awareness”?

The authors also note another important limitation, namely that the Internet population (where they recruited people from) “is probably different from a clinical population as it contains a subgroup of subjects who are not willing to undergo treatment and are thus less compliant with the psychiatric health care system”.

Summary

It is clear we need better ways to help people. And we need them yesterday.

 

Reference

I’d encourage you to read the paper for yourself. The reference (and link) is:

Moritz, S., Andreou, C., Kilngberg, S., Thoring, T., Peters, M. J. V. (2013). Assessment of subjective cognitive and emotional effects of antipsychotic drugs. Effect by defect? Neuropharmacology. http://dx.doi.org/10.1016/j.neuropharm.2013.04.039

If you can’t access the paper on-line, I’m that sure if you emailed the authors that they would be happy to send you a copy for your own examination.