Violence and Voices

One of my colleagues posted this NYTimes  reference to my Facebook feed this morning.  It is written by anthropologist T.M. Luhrmann.  She has a number of references in Medline relevant to this article.  Her basic thesis is that violent or aggressive auditory hallucinations experienced by people with psychotic disorders are culturally determined.  She concludes with the irony that the cultural factors responsible for a lack of will to initiate any meaningful gun control measures may be responsible for more violent auditory hallucinations than are experienced in other cultures.

What is the evidence?  She sites a cross cultural study of 40 people with schizophrenia in India and the United States.  Across cultures the horrible voice in India were focused on sexual themes and in the US they were focused more on aggression and torture.  There were other directive voices focused on routine directions.  Not a lot of detail.  As a guy who has talked with hundreds of people who were experiencing voices - the common ones are basically background noise like people mumbling or talking at a volume that cannot be understood.  Clearer voices clearly comment on the person experiencing them.  The comments can vary from routine such as what the person is doing to very negative commentary or ridiculing them.  At the extremes voices tell people to harm themselves or others or commit suicide.  Those are the typical voices that psychiatrists are trained to ask about for the purpose of assessing dangerousness, but recent studies show that they are probably poor predictors of actual violent acts in clinical settings.

What about the larger observation that voices would incorporate culturally relevant elements?  It seems to me that would be a given.  As I considered the problem I recalled reading J. Allan Hobson's book The Dreaming Brain when it first came out. He describes acquiring the dream journal of the Engine Man who recorded his dreams in great detail and without interpretation in 1939.  The Engine Man was "fascinated by railway trains" and the content of his dreams that he describes and draws contains a lot of that subject material.  Railway trains were the technology of the day.  They were part of the culture and the conscious states of me interested in technology.  Like the Engine Man it is difficult to conceive of a person experiencing voices or delusions without a cultural context.

It is difficult to imagine scenarios that lead to voices de novo without exposure to a plausible or even science fiction origin.  Hence the common scenario that there is an agency projecting these voices as the most likely cause.  It can also imply motivation for the perceptual changes as well as the content.   I doubt that voices originating as a beam from the police, the CIA, the FBI or Homeland Security occurred before these agencies were invented.

The other association I had is the theory (or axiom) that the prognosis of schizophrenia is much better in the developing world.  This idea came about as the result of a number of World Health Organization Studies and others done in the 1970s to 2000s.  Those studies suggest a better prognosis for schizophrenia in the developing world.  That theory has been called into question based on methodological considerations by Cohen et al.  At the anthropological level, the argument by Dr. Luhrmann reminds me of a similar argument about whether or not primitive peoples were inherently peaceful and became aggressive only after being influenced by social organization.  Large scale warfare only becomes possible as the institutions of civilized society grow.  Primitive man by nature was inherently peaceful and would get involved only in small scale conflicts around issues like marriage and property.  Kealy refers to this as the Myth of the Peaceful Savage.  He dispels that myth in his book War Before Civilization and points out that prehistoric man was as aggressive and violent as modern man.  Violent and aggressive solutions appear to be universal and it is likely that the culture in America is no more violent than what people experience across the world.  The only plausible cultural argument that is rapidly vanishing is the exposure to media violence on a 24/7 basis.  At anthropological level, the basic question seems to be why all human societies seem to regard warfare and aggression as an ultimate solution to unresolved conflict.

The larger issue of course is the fact that the experience of hearing voices is much more than that.  The entire conscious state is affected.  There is not a linear sequence of events that proceeds form a voice to an action.  Practically everyone with that experience has a substantial change in their conscious state.  The usual stream of consciousness is affected as well as mood state and decision making biases.  At times that is detected there can be what appears to be a complete change in the personality of the affected person.  The decisions that they currently make cannot be predicted by your past experience with them.

There are several psychotherapeutic approaches to the problem.  From a psychiatrist's perspective is is generally necessary and advisable to discuss the voices at some level with the patient.  An explanation is necessary that is more than an incomplete biological one as: "You are hearing voices - take this medication and it will get rid of them."  Most people are interested in what it means and culturally and individually based meanings are often useful.  Some of the preliminary cognitive behavioral therapy of hallucinations emphasizes the need to decrease personal meaning and when that occurs the voices may become less intense and disappear.  It should really come as no surprise that talking about voices in certain ways modifies the experience of hearing them or even results in them disappearing.  I would liken it to making a conscious decision to wake up during a dream that you don't want to have and then realizing that the dream is gone.  Although it has not been investigated I would speculate that this ability would be proportional to the degree that a person's usual conscious state has been affected.


George Dawson, MD, DFAPA

Hobson JA.  The Dreaming Brain.  Basic Books, Inc.  New York, 1988.

TM Luhrmann.  The Violence in Our Heads.  New York Times September 19, 2013.

Cohen A, Patel V, Thara R, Gureje O. Questioning an axiom: better prognosis for schizophrenia in the developing world? Schizophr Bull. 2008 Mar;34(2):229-44. Epub 2007 Sep 28. Review. PubMed PMID: 17905787; PubMed Central PMCID: PMC2632419.

Kleinman A. Commentary on Alex Cohen et al: "Questioning an axiom: better prognosis for schizophrenia in the developing world". Schizophr Bull. 2008 Mar;34(2):249-50. Epub 2007 Dec 3. PubMed PMID: 18056682; PubMed Central PMCID: PMC2632393.

Keeley LH.  War Before Civilization - The Myth of the Peaceful Savage.  Oxford University Press, 1996.

A Neurologist Gets High

Well known neurologist and author Oliver Sacks has written an essay in the New Yorker about his drug experiences in the 1960s.  From about 1963-1967 Dr. Sacks ingested various compounds including cannabis, amphetamines, intravenous morphine, LSD, morning glory seeds, Artane (trihexyphenidyl hydrochloride) and massive doses of chloral hydrate with an accompanying withdrawal state.  He does an excellent job of describing various intoxication and delirium states.  As an example he describes his experience reading a text on migraines from 1873 while taking amphetamine:

"...In a sort of catatonic concentration that in 10 hours I scarcely moved a muscle or wet my lips, I read steadily through "Megrim"....At times I was unsure if I was reading the book or writing it...." p. 47

In my current professional iteration as an addiction psychiatrist these are familiar scenarios.  At some level Sacks realizes that he is lucky to have survived chloral hydrate withdrawal induced delirium tremens and amphetamine-induced tachycardia up to the 200 beats per minute range with an unknown blood pressure.  Vivid visual and auditory hallucinations and a distorted sense of time are described.  There is also the familiar interpersonal dimension that gets activated when a person's life is affected by drug use - concerned colleagues that implore him to seek help and take care of himself.

Dr. Sacks is an intellectual and this is presented in an intellectual context that may not have been very evident at the time of the experimentation.  He describes the sociocultural antecedents of a need for chemical transcendance that has been present throughout human history.  He proceeds to describe some of the relevant historical writings of physicians and other intellectuals.

The usual debate about whether or not there is any utility in taking life threatening amounts of drugs occurs in the text and on the podcast.  Not surprisingly, intellectuals derive insights from their experiences and taking drugs is no exception.  In  the article, the revolution in neurochemistry was one of the preludes to the period of experimentation.  The problems with psychotic symptoms and manic states are well described as well as what states might be the preferred ones.  We learn on the podcast that these experiences have provided insights into possible brain mechanisms and that this might be part of the basis for the author's new book Hallucinations that comes out in the fall.

Dr. Sacks describes himself as an observer and explorer of psychotic symptoms and how that seems to be protective when he is tripping.  What is missing here compared to the people I have talked with is a highly subjective response that increases the risk for drug use.  I typically hear about intense euphoria, high energy, and increased competence in physical, intellectual and social spheres.  Not having that response may be protective and may allow one to avoid the risks of ongoing chemical use.  In some cases there may just be a compulsion to recreate the drug induced state.  The essay may have been a lot more complicated or written by someone else if those descriptions were there.

George Dawson, MD, DFAPA

Oliver Sacks.  Altered States - Self experiments in chemistry.  The New Yorker, August 27, 2012: 40-47.

Oliver Sacks.  Podcast: The New Yorker Out Loud.