Hallucinations

by Oliver Sacks

  The air was filled with a big noise and I tried to move. I felt the heaven was going down upon the earth and that it had engulfed me. I have really touched God. He came into me myself, yes God exists, I cried, and I don’t remember anything else. You all, healthy people, he said, can’t imagine the happiness which we epileptics feel during the second or so before our fit.… I don’t know if this felicity lasts for seconds, hours or months, but believe me, for all the joys that life may bring, I would not exchange this one.

  He gave similar descriptions on a number of other occasions, and endowed several of the characters in his novels with seizures akin to, and sometimes identical with, his own. One such involves Prince Myshkin in The Idiot:

  During these moments as rapid as lightning, the impression of the life and the consciousness were in himself ten times more intense. His spirit and his heart were illuminated by an immense sense of light; all his emotions, all his doubts, all his anxiety calmed together to be changed into a sovereign serenity made up of lighted joy, harmony and hope; then, his reason was raised up to the understanding of the final cause.

  There are also descriptions of ecstatic seizures in The Devils, The Brothers Karamazov, and The Insulted and the Injured, while in The Double there are descriptions of “forced thinking” and “dreamy states” almost identical with what Hughlings Jackson was describing at much the same time in his great neurological articles.

  Over and above his ecstatic auras—which always seemed to Dostoevsky revelations of ultimate truth, direct and valid knowledge of God—there were remarkable and progressive changes in his personality throughout the later parts of his life, his time of greatest creativity. Théophile Alajouanine, a French neurologist, observed that these changes were clear when one compared Dostoevsky’s early, realistic works with the great, mystical novels he wrote in later life. Alajouanine suggested that “epilepsy had created in the person of Dostoevsky a ‘double man’ … a rationalist and a mystic; each having the better of the other according to the moment … [and] more and more the mystical one seems to have prevailed.”

  It was this change, seemingly progressing even between Dostoevsky’s seizures (“interictally,” in neurological jargon), that especially fascinated the American neurologist Norman Geschwind, who wrote a number of papers on the subject in the 1970s and 1980s. He noted Dostoevsky’s increasingly obsessive preoccupation with morality and proper behavior, his growing tendency to “get embroiled in petty arguments,” his lack of humor, his relative indifference to sexuality, and, despite his high moral tone and seriousness, “a readiness to become angry on slight provocation.” Geschwind spoke of all this as an “interictal personality syndrome” (it is now called “Geschwind syndrome”). Patients with it often develop an intense preoccupation with religion (Geschwind referred to this as “hyper-religiosity”). They may also develop, like Stephen L., compulsive writing or unusually intense artistic or musical passions.

  Whether or not an interictal personality syndrome develops—and it does not seem to be universal or inevitable in those who have temporal lobe epilepsy—there is no doubt that those who have ecstatic seizures may be profoundly moved by them, and even actively seek to have more such seizures. In 2003, Hansen Asheim and Eylert Brodtkorb, in Norway, published a study of eleven patients with ecstatic seizures; eight of them wished to experience their seizures again, and of these, five found ways to induce them. More than any other sort of seizure, ecstatic seizures may be felt as epiphanies or revelations of a deeper reality.

  Orrin Devinsky, a former student of Geschwind’s, has been a pioneer himself in the investigation of temporal lobe epilepsy and the great range of neuropsychiatric experiences which may be associated with it—autoscopy, out-of-body experiences, déjà vu and jamais vu, hyperfamiliarity, and ecstatic states during seizures, as well as personality changes between seizures. He and his colleagues have been able to perform clinical and video EEG monitoring in patients as they are having ecstatic-religious seizures, and thus to observe the precise coinciding of their “theophanies” with seizure activity in temporal lobe seizure foci (nearly always these are right-sided).9

  Such revelations may take different forms; Devinsky has told me of one woman who, following a head injury, started to have brief episodes of déjà vu and a strange, indescribable smell. After a cluster of these complex partial seizures, she entered an exalted state in which God, with the form and voice of an angel, told her to run for Congress. Though she had never been religious or political before, she acted on God’s words at once.10

  On occasion, ecstatic hallucinations can be dangerous, although this is very rare. Devinsky and his colleague George Lai described how one of their patients had a seizure-related vision in which “he saw Christ and heard a voice that commanded him to kill his wife and then himself. He proceeded to act upon the hallucinations,” killing his wife and then stabbing himself. This patient ceased to have seizures after the seizure focus in his right temporal lobe was removed.

  Such epileptic hallucinations bear a considerable resemblance to the command hallucinations of psychosis, even though the epileptic patient may have no psychiatric history. It takes a strong (and skeptical) person to resist such hallucinations and to refuse them either credence or obedience, especially if they have a revelatory or epiphanic quality and seem to point to a special—and perhaps exalted—destiny.

  As William James observed, an acute and passionate religious conviction in a single person can sway thousands of people. The life of Joan of Arc exemplified this. People have puzzled for nearly six hundred years as to how a farmer’s daughter with no formal education could have found such a sense of mission and succeeded in getting thousands of others to aid her in an attempt to drive the English out of France. The early hypotheses of divine (or diabolic) inspiration have given way to medical ones, with psychiatric diagnoses vying with neurological ones. Much evidence is available from the transcripts of her trial (and her “rehabilitation” twenty-five years later) and from the recollections of contemporaries. None of these is conclusive, but they do suggest, at least, that Joan of Arc may have had temporal lobe epilepsy with ecstatic auras.

  Joan experienced visions and voices from the age of thirteen. These came in discrete episodes lasting seconds or minutes at most. She was very frightened by the first visitation, but later she derived great joy and an explicit sense of mission from her visions. The episodes were sometimes precipitated by the sounds of church bells. Joan described her first “visitations”:

  I was thirteen when I had a Voice from God for my help and guidance. The first time that I heard this Voice, I was very much frightened; it was mid-day, in the summer, in my father’s garden … I heard this Voice to my right, towards the Church; rarely do I hear it without its being accompanied also by a light. This light comes from the same side as the Voice. Generally it is a great light.… When I heard it for the third time, I recognized that it was the Voice of an Angel. This voice has always guarded me well, and I have always understood it; it instructed me to be good and to go often to Church; it told me it was necessary for me to come into France … it said to me two or three times a week: “You must go into France.” … It said to me: “Go, raise the siege which is being made before the City of Orleans. Go!” … and I replied that I was but a poor girl, who knew nothing of riding or fighting.… There is never a day when I do not hear this Voice; and I have much need of it.

  Many other aspects of Joan’s putative seizures, as well as evidence of her clarity, her reasonableness, and her modesty, were explored in a 1991 article by the neurologists Elizabeth Foote-Smith and Lydia Bayne. While they present a very plausible case, other neurologists disagree, and one cannot hope to see the matter definitively resolved. The evidence is soft, as it must be for all historical cases.

  Ecstatic or religious or mystical seizures occur in only a small number of those who have temporal lobe epilepsy. Is this because there is something special—a preexisting disposition to religion or metaphysica
l belief—in these particular people? Or is it because the seizure stimulates particular parts of the brain that serve to mediate religious feeling?11 Both, of course, could be the case. And yet quite skeptical people, indifferent to religion, not given to religious belief, may—to their own astonishment—have a religious experience during a seizure.

  Kenneth Dewhurst and A. W. Beard, in a 1970 paper, provided several examples of this. One related to a bus conductor who had an ecstatic seizure while collecting fares:

  He was suddenly overcome with a feeling of bliss. He felt he was literally in Heaven. He collected the fares correctly, telling his passengers at the same time how pleased he was to be in Heaven.… He remained in this state of exaltation, hearing divine and angelic voices, for two days. Afterwards he was able to recall these experiences and he continued to believe in their validity.… During the next two years, there was no change in his personality; he did not express any peculiar notions but remained religious.… Three years later, following three seizures on three successive days, he became elated again. He stated that his mind had “cleared.” … During this episode he lost his faith.

  He now no longer believed in heaven and hell, in an afterlife, or in the divinity of Christ. This second conversion—to atheism—carried the same excitement and revelatory quality as the original religious conversion. (Geschwind, in a 1974 lecture subsequently published in 2009, noted that patients with temporal lobe epilepsy might have multiple religious conversions and described one of his own patients as “a girl in her twenties who is now on her fifth religion.”)

  Ecstatic seizures shake one’s foundations of belief, one’s world picture, even if one has previously been wholly indifferent to any thought of the transcendent or supernatural. And the universality of fervent mystical and religious feelings—a sense of the holy—in every culture suggests that there may indeed be a biological basis for them; they may, like aesthetic feelings, be part of our human heritage. To speak of a biological basis and biological precursors of religious emotion—and even, as ecstatic seizures suggest, a very specific neural basis, in the temporal lobes and their connections—is only to speak of natural causes. It says nothing of the value, the meaning, the “function” of such emotions, or of the narratives and beliefs we may construct on their basis.

  1. When Hippocrates wrote “On the Sacred Disease,” he was bowing to the then-popular notion of epilepsy’s divine origin, but he dismisses this in his opening sentence: “The disease called sacred … appears to me no more sacred than other diseases, but has a natural cause from which it originates, like other affections.”

  2. Beginning in 1861, when he was twenty-four, Hughlings Jackson published many major papers—on epilepsy, aphasia, and other subjects, as well as what he called “evolution and dissolution in the nervous system.” A selection of these, filling two large volumes, was published in 1931, twenty years after his death. In his later years, Jackson published a series of twenty-one short, gemlike papers in the Lancet under the title Neurological Fragments. These were collected and published in book form in 1925.

  3. David Ferrier, a contemporary of Gowers’s, moved to London in 1870, where he was mentored by Hughlings Jackson (Ferrier became a great experimental neurologist in his own right—he was the first to use electrical stimulation to map the monkey’s brain). One of Ferrier’s epileptic patients had a remarkable synesthetic aura, in which she would experience “a smell like that of green thunder.” (This is quoted by Macdonald Critchley in his 1939 paper on visual and auditory hallucinations.)

  4. Hughlings Jackson described such seizures in 1875 and thought they might originate from a structure in the brain located beneath the olfactory cortex, the uncinate gyrus. In 1898 Jackson and W. S. Colman were able to confirm this by autopsy in Dr. Z., a patient who had died of an overdose of chloral hydrate. (More recently, David C. Taylor and Susan M. Marsh have recounted the fascinating history of Dr. Z., an eminent physician named Arthur Thomas Myers whose brother, F. W. H. Myers, had founded the Society for Psychical Research.)

  5. In the 1946 film A Matter of Life and Death (called Stairway to Heaven in the United States), David Niven’s character, a pilot, has complex epileptic visions that are always preceded by an olfactory hallucination (the smell of burnt onions) and a musical one (a recurrent theme of six notes). Diane Friedman has written a fascinating book about this, indicating how meticulous the director, Michael Powell, was in consulting neurologists about the forms of epileptic hallucinations.

  6. Penfield was a great physiologist as well as a neurosurgeon, and in the process of searching for epileptic foci, he was able to map most of the basic functions of the living human brain. He showed, for example, exactly where sensations and movements of specific body parts were represented in the cerebral cortex—his sensory and motor homunculi are iconic. Like Weir Mitchell, Penfield was an engaging writer, and after he and Herbert Jasper published their magnum opus, Epilepsy and the Functional Anatomy of the Human Brain, in 1958, he continued to write about the brain, as well as writing novels and biographies, until his death at eighty-six.

  7. For Gowers and his contemporaries in the early twentieth century, memories were imprints in the brain (as for Socrates they were analogous to impressions made in soft wax)—imprints that could be activated by the act of recollection. It was not until the crucial studies of Frederic Bartlett at Cambridge in the 1920s and 1930s that this classical view could be disputed. Whereas Ebbinghaus and other early investigators had studied rote memory—how many digits could be remembered, for instance—Bartlett presented his subjects with pictures or stories and then questioned and requestioned them over a period of months. Their accounts of what they had seen or heard were somewhat different (and sometimes quite transformed) on each re-remembering. These experiments convinced Bartlett to think in terms not of a static thing called “memory,” but rather a dynamic process of “remembering.” He wrote:

  Remembering is not the re-excitation of innumerable fixed, lifeless and fragmentary traces. It is an imaginative reconstruction, or construction, built out of the relation of our attitude towards a whole active mass of organized past reactions or experience.… It is thus hardly ever really exact.

  8. Penfield sometimes used the term “flashback” for experiential hallucinations. The term is also used in quite different contexts, as in post-traumatic flashbacks, where there are recurrent hallucinatory replayings of traumatic events.

  The term “flashback” is also used for a sudden, transient reexperiencing of a drug effect—suddenly feeling, for example, the effects of LSD, even though one has not taken it for months.

  9. One such patient, who had very little in the way of religious interests as an adult, had his first religious seizure at a picnic, as Devinsky described to me: “His friends observed at first that he stared, became pale, and was unresponsive. Then suddenly, he began to run in circles for two or three minutes yelling, ‘I am free! I am free!… I am Jesus! I am Jesus!’ ”

  The patient later had a similar seizure which was recorded on video EEG, and, just before the seizure, Devinsky noted, the patient was slow to respond and disoriented regarding time and place:

  When asked if there was anything wrong, he replied: “nothing is wrong, I am doing well … I am very happy” and when asked whether he knew where he was, he replied with a smile and a surprised look: “Of course I know. I am in heaven right now;… I am fine.”

  He remained in this state for ten minutes, then went on to a generalized seizure. Later, he remembered his ecstatic aura “as if it were a vivid and happy dream” from which he had now awoken, but he had no memory of the questions put to him during the aura.

  10. She ran as a Republican in a district that had been Democratic for a very long time, and lost by only a narrow margin. Whenever she appeared in public during her campaign, she said that God had told her to run, and this apparently persuaded thousands of people to vote for her, despite her manifest lack of political experience or skills.

&nbs
p; 11. The evidence here has been discussed in a number of books, including Kevin Nelson’s The Spiritual Doorway in the Brain: A Neurologist’s Search for the God Experience. It is also the theme of a novel, Lying Awake, by Mark Salzman; the protagonist is a nun who has ecstatic seizures in which she communes with God. Her seizures, it turns out, are caused by a tumor in her temporal lobe, and it must be removed before it enlarges and kills her. But will its removal also remove her portal to heaven, preventing her from ever communing with God again?

  9

  Bisected: Hallucinations in the Half-Field

  One does not see with the eyes; one sees with the brain, which has dozens of different systems for analyzing the input from the eyes. In the primary visual cortex, located in the occipital lobes, at the back of the brain, there are point-to-point mappings of the retina onto the cortex, and it is here that light, shape, orientation, and location in the visual field are represented. Impulses from the eyes take a circuitous route to the cerebral cortex, some of them crossing to the opposite side of the brain as they do so, so that the left half of the visual field of each eye goes to the right occipital cortex, and vice versa. If, therefore, one occipital lobe is damaged (as by a stroke, for example), there will be blindness or impaired vision in the opposite half of the visual field—a hemianopia.