Authors: Oliver Sacks
Silas Weir Mitchell, working with soldiers who had lost limbs in the Civil War, was the first to understand the neurological nature of phantom limbs—they had previously been regarded, if at all, as a sort of bereavement hallucination. By a curious irony, Mitchell himself suffered a bereavement hallucination following the sudden death of a very close friend, as Jerome Schneck described in a 1989 article:
A reporter brought the unexpected news one morning and Mitchell, greatly shaken, went up to tell his wife. On the way back downstairs he had an odd experience: he could see the face of Brooks, larger than life, smiling, and very distinct, yet looking as if it were made of dewy gossamer. When he looked
down, the vision disappeared, but for ten days he could see it a little above his head to the left.
Bereavement hallucinations, deeply tied to emotional needs and feelings, tend to be unforgettable, as Elinor S., a sculptor and printmaker, wrote to me:
When I was fourteen years old, my parents, brother and I were spending the summer at my grandparents’ house as we had done for many previous years. My grandfather had died the winter before.
We were in the kitchen, my grandmother was at the sink, my mother was helping and I was still finishing dinner at the kitchen table, facing the back porch door. My grandfather walked in and I was so happy to see him that I got up to meet him. I said, “Grampa,” and as I moved towards him, he suddenly wasn’t there. My grandmother was visibly upset, and I thought she might have been angry with me because of her expression. I said to my mother that I had really seen him clearly, and she said that I had seen him because I wanted to. I hadn’t been consciously thinking of him and still do not understand how I could have seen him so clearly.
I am now seventy-six years of age and still remember the incident and have never experienced anything similar.
Elizabeth J. wrote to me about a grief hallucination experienced by her young son:
My husband died thirty years ago after a long illness. My son was nine years old at the time; he and his dad ran together on a regular basis. A few months after my husband’s death, my son
came to me and said that he sometimes saw his father running past our home in his yellow running shorts (his usual running attire). At the time, we were in family grief counselling, and when I described my son’s experience, the counsellor did attribute the hallucinations to a neurologic response to grief. This was comforting to us, and I still have the yellow running shorts.
A general practitioner in Wales, W. D. Rees, interviewed nearly three hundred recently bereft people and found that almost half of them had had illusions or full-fledged hallucinations of a dead spouse. These could be visual, auditory, or both—some of the people interviewed enjoyed conversations with their hallucinated spouses. The likelihood of such hallucinations increased with the length of marriage, and they might persist for months or even years. Rees considered these hallucinations to be normal and even helpful in the mourning process.
For Susan M., bereavement stimulated a particularly vivid, multisensory experience a few hours after her mother died: “I heard the squeaking of the wheels of her walker in the hallway. She walked into the room shortly afterward and sat down on the bed next to me. I could feel her sit down on the mattress. I spoke to her and said I thought she had died. I don’t remember exactly what she said in return—something about checking in with me. All I know is I could feel her there and it was frightening but also comforting.”
Ray P. wrote to me after his father died at the age of eighty-five, following a heart operation. Although Ray had rushed to the hospital, his father had already lapsed into a coma. An hour before his father died, Ray whispered to him: “Dad, it’s
Ray. I’ll take care of mom. Don’t worry, everything is going to be alright.” A few nights later, Ray wrote, he was awakened by an apparition:
I awoke in the night. I did not feel groggy or disoriented and my thoughts and vision were clear. I saw someone sitting on the corner of my bed. It was my Dad, wearing his khaki slacks and tan polo shirt. I was lucid enough to wonder initially if this could be a dream but I was certainly awake. He was opaque, not ethereal in any way, the nighttime Baltimore light pollution in the window behind him did not show through. He sat there for a moment and then said—did he speak or just convey the thought?—“Everything is all right.”
I turned and swung my feet to the floor. When I looked [back toward] him, he was gone. I stood and went to the bathroom, got a drink of water, and went back to bed. My dad never returned. I do not know whether this was a hallucination or something else, but since I provisionally do not believe in the paranormal, it must have been.
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The hallucinations of grief may sometimes take a less benign form. Christopher Baethge, a psychiatrist, has written about two mothers who lost young children in a particularly traumatic way. Both had multisensory hallucinations of their dead daughters—seeing them, hearing them, smelling them, being touched by them. And both were driven to delusional, otherworldly explanations of their hallucinations: one believed that “this was her daughter’s attempt to establish contact with her from another world, a world in which her daughter continues to exist”; the other heard her daughter cry out, “Mamma, don’t be afraid, I’ll come back.”
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R
ecently I tripped over a box of books in my office, fell headlong, and broke a hip. This seemed to happen in slow motion. I thought,
I have plenty of time to put out my arm to break the fall
, but then—suddenly—I was on the floor, and as I hit, I felt the crunch in my hip. With near-hallucinatory vividness, in the next few weeks, I reexperienced my fall; it replayed itself in my mind and body. For two months I avoided the office, the place where I had fallen, because it provoked this quasi-hallucination of falling and the crunch of breaking bone. This is one example—a trivial one, perhaps—of a reaction to trauma, a mild traumatic stress syndrome. It is largely
resolved now, but it will, I suspect, lurk in the depths as a traumatic memory that may be reactivated under certain conditions for the rest of my life.
Much deeper trauma and consequent PTSD (post-traumatic stress disorder) may affect anyone who has lived through a violent crash, a natural cataclysm, war, rape, abuse, torture, or abandonment—any experience that produces a terrifying fear for one’s own safety or that of others.
All of these situations can produce immediate reactions, but there may also be, sometimes years later, post-traumatic syndromes of a malignant and often persistent sort. It is characteristic of these syndromes that, in addition to anxiety, heightened startle reactions, depression, and autonomic disorders, there is a strong tendency to obsessive rumination on the horrors which were experienced—and, not infrequently, sudden flashbacks in which the original trauma may be reexperienced in its totality with every sensory modality and with every emotion that was felt at the time.
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These flashbacks, though often spontaneous, are especially liable to be evoked by objects, sounds, or smells associated with the original trauma.
The term “flashback” may not do justice to the profound and sometimes dangerous delusional states that can go with post-traumatic hallucinations. In such states, all sense of the present may be lost or misinterpreted in terms of hallucination and delusion. Thus the traumatized veteran, during a flashback, may be convinced that people in a supermarket
are enemy soldiers and—if he is armed—open fire on them. This extreme state of consciousness is rare but potentially deadly.
One woman wrote to me that, having been molested as a three-year-old and assaulted at the age of nineteen, “for both events smell will bring back strong flashbacks.” She continued:
I had my first flashback of being assaulted as a child when a man sat next to me on a bus. Once I smelled [his] sweat and body odor, I was not on that bus anymore. I was in my neighbor’s garage and I remembered everything. The bus driver had to ask me to get off the bus when we arrived at our destination. I lost all sense of time and place.
Particularly severe and long-lasting stress reactions may occur after rape or sexual assault. In a case reported by Terry Heins and his colleagues, for example, a fifty-five-year-old woman who had been forced to watch her parents’ sexual intercourse as a young child and then forced to have intercourse with her father at the age of eight experienced repeated flashbacks of the trauma as an adult, as well as “voices”—a post-traumatic stress syndrome that was misdiagnosed as schizophrenia and led to psychiatric hospitalization.
People with PTSD are also prone to recurrent dreams or nightmares, often incorporating literal or somewhat disguised repetitions of the traumatic experiences. Paul Chodoff, a psychiatrist writing in 1963 about the effects of trauma in concentration camp survivors, saw such dreams as a hallmark of the syndrome and noted that in a surprising number of cases, they
were still occurring a decade and a half after the war.
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The same is true of flashbacks.
Chodoff observed that obsessive rumination on concentration camp experiences might diminish in some people with the passage of time, but others
communicated an uncanny feeling that nothing of real significance had happened in their lives since their liberation, as they reported their experiences with a vivid immediacy and wealth of detail which almost made the walls of my office disappear, to be replaced by the bleak vistas of Auschwitz or Buchenwald.
Ruth Jaffe, in a 1968 article, described one concentration camp survivor who had frequent attacks in which she relived her experience at the gates of Auschwitz, where she saw her sister led off into a group destined for death but could do nothing to save her, even though she tried to sacrifice herself instead. In her attacks, she saw people entering the gates of the camp and heard her sister’s voice calling, “Katy, where are you? Why do you leave me?” Other survivors are haunted by olfactory flashbacks, suddenly smelling the gas ovens—a smell which, more than anything else, brings back the horror of the camps. Similarly, the smell of burning rubble lingered around the World Trade Center for months after 9/11—and continued as
a hallucination to haunt some survivors even when the actual smell was gone.
There is a large body of literature on both acute stress reactions and delayed ones following natural disasters like tsunamis or earthquakes. (These occur in very young children too, though they may tend to reenact rather than hallucinate or reexperience the disaster.) But PTSD seems to have an even higher prevalence and greater severity following violence or disaster that is man-made; natural disasters, “acts of God,” seem somehow easier to accept. This is the case with acute stress reactions, too: I see it often with my patients in hospital, who can show extraordinary courage and calmness in facing the most dreadful diseases but fly into a rage if a nurse is late with a bedpan or a medication. The amorality of nature is accepted, whether it takes the form of a monsoon, an elephant in musth, or a disease; but being subjected helplessly to the will of others is not, for human behavior always carries (or is felt to carry) a moral charge.
F
ollowing the First World War, some physicians felt that there must be an organic brain disturbance underlying what were then called war neuroses, which seemed unlike “normal” neuroses in many ways.
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The term “shell shock” was coined with the notion that the brains of these soldiers had been mechanically deranged by the repeated concussion of the new high-explosive shells introduced in this war. There
was as yet no formal recognition of the delayed effects of the severe trauma of soldiers who endured shells and mustard gas for days on end, in muddy trenches that were filled with the rotting corpses of their comrades.
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Recent work by Bennet Omalu and others has shown that repeated concussion (even “mild” concussions that do not cause a loss of consciousness) can result in a chronic traumatic encephalopathy, causing memory and cognitive impairment; this may well exacerbate tendencies to depression, flashbacks, hallucination, and psychosis. Such chronic traumatic encephalopathy, along with the psychological trauma of war and injury, has been linked to the rising incidence of suicide among veterans.
That there may be biological as well as psychological determinants of PTSD would not have surprised Freud—and the treatment of these conditions may require medication as well as psychotherapy. In its worst forms, though, PTSD can be a nearly intractable disorder.
T
he concept of dissociation would seem crucial not only to understanding conditions like hysteria or multiple personality disorder but also to the understanding of post-traumatic syndromes. There may be an instant distancing or dissociation when a life-threatening situation occurs, as when a driver about to crash sees his car from a distance, almost like a spectacle
in a theater, with a sense of being a spectator rather than a participant. But the dissociations of PTSD are of a more radical kind, for the unbearable sights, sounds, smells, and emotions of the hideous experience get locked away in a separate, subterranean chamber of the mind.
Imagination is qualitatively different from hallucination. The visions of artists and scientists, the fantasies and daydreams we all have, are located in the imaginative space of our own minds, our own private theaters. They do not normally appear in external space, like the objects of perception. Something has to happen in the mind/brain for imagination to overleap its boundaries and be replaced by hallucination. Some dissociation or disconnection must occur, some breakdown of the mechanisms that normally allow us to recognize and take responsibility for our own thoughts and imaginings, to see them as ours and not as external in origin.
It is not clear, however, that such a dissociation can explain everything, for quite different sorts of memory may be involved. Chris Brewin and his colleagues have argued that there is a fundamental difference between the extraordinary flashback memories of PTSD and those of ordinary autobiographic memory and have provided much psychological evidence for such a difference. Brewin et al. see a radical distinction between autobiographic memories, which are verbally accessible, and flashback memories, which are not verbally or voluntarily accessible but may erupt automatically if there is any reference to the traumatic event or something (a sight, a smell, a sound) associated with it. Autobiographic memories are not isolated—they are embedded in the context of an entire life, given a broad and deep context and perspective—and they can be revised in
relation to different contexts and perspectives. This is not the case with traumatic memories. The survivors of trauma may be unable to achieve the detachment of retrospection or recollection; for them the traumatic events, in all their fearfulness and horror, all their sensorimotor vividness and concreteness, are sequestered. The events seem to be preserved in a different form of memory, isolated and unintegrated.