I have just returned from Nice. European Psychiatrists were gathered together for 4 days talking about the issues that most concern us. At the heart of psychiatry is a concern for the individual who is in distress. The distress is subjectively experienced and has to be communicated in words, in language, in the main. But, there is a dilemma in that in contemporary society, the objective, the measurable has become the marker of significance and importance. Tumours are okay but hallucinations are not! So, there is an understandable search for independent markers, for surrogates, that itself speaks to the devaluation of what is authentically experienced by the person, the sole subject of our concern, another human being.
This problem of how to value the primary inner subjective experience that is the currency of our encounter with patients in the clinical space is the topic of this blog. But, only in an indirect way. I want to talk about Schreber’s accounts of his verbal hallucinations as an exemplar of the importance of attending to subjective experience.
Daniel Schreber (1842-1911) is regarded, by many people, as the most important psychiatric patient because of the range of his influence on psychiatric thinking, terminology and concepts: Bleuler (1911) Dementia Praecox or the group of schizophrenias, Freud (1911) Psychoanalytic notes upon an autobiographical account of a case of paranoia Jaspers (1913) General psychopathology, & Sass (1994) The paradoxes of delusion. He was a candidate for Reichstag in 1884, and promoted to the high office of President of Panel of Judges at Court of Appeal Dresden in 1893. He was 1st admitted into hospital December 1884 under Professor Fleschig, discharged fully recovered in June 1885. His 2nd episode was in 1893, six weeks after taking up the role of Senatsprasident. He was probably discharged in 1903. His final admission was ?1907-1911.
Schreber derived from an illustrious family: His father was Daniel Schreber (1808-1861) was physician & lecturer at Leipzig University where he founded Institute of Orthopaedics. Allotments in Germany are named after him Schrebergarten. His grandfather was a lawyer, Daniel Schreber (d 1777), Professor of Agriculture & Economics. Seventeen of his books are at British Museum. Daniel Schreber (son of above) (1739-1810), great-uncle, Professor of Medicine & Superintendent of the Botanical Gardens University of Erlangen He was knighted 1791 & was Fellow of Royal Society London, 31 of his books are at British Museum.
Schreber’s account is a rich source of psychopathology. He described his experiences of verbal hallucinations amongst other experiences. In the examples that follow below, Schreber details the characteristics of his experiences.
During several nights when I could not get to sleep, a recurrent crackling noise in the wall of our bedroom became noticeable at shorter or longer intervals; time and again it woke me as I was about to go to sleep. Naturally we thought of a mouse although it was very extraordinary that a mouse should have found its way to the first floor of such a solidly built house
But having heard similar noises innumerable times since then, and still hearing them around me everyday in daytime and at night, I have come to recognise them as undoubted divine miracles they are called “interferences” by the voices talking to me and I must at least suspect, without being too definite about it, that even then it was already a matter of such a miracle; in other words that right from the beginning the more or less definite intention existed to prevent my sleep and later my recovery from the illness resulting from the insomnia for a purpose which cannot at this stage be further specified
All these souls spoke to me as voices more or less at the same time without one knowing of the presence of the others. Everyone who realises that all this is not just the morbid offspring of my fantasy will be able to appreciate the unholy turmoil they caused in my head..for a long time now the talk of the voices has consisted only of a terrible, monotonous repetition of ever recurring phrases.
The “voices” manifest themselves in me as nervous impulses, and always have the character of soft lisping noises sounding like distinct human words with only the exception of the night, at the beginning of July 1894. Both their content and the rate at which they are spoken have changed considerably in the course of the years. The most important points about them I have already mentioned; predominant is their absolute nonsense as the phrases are stylistically incomplete, and many terms of abuse
The hissing of the voices is now best compared to the sound of sand trickling from an hourglass. I can distinguish individual words hardly at all or only with the greatest difficulty. Naturally I do not trouble to do this, on the contrary I try to ignore what is spoken. However, when I do hear individual words from well-known phrases, I cannot prevent my memory supplying the continuation so that the “automatic remembering-thought”, as this phenomenon is called in the soul language, itself causes my nerves to vibrate till the sentence is finished
I have quoted Schreber extensively to make the point, that ought not to need making, that psychopathology, abnormal phenomena are impoverished by an approach that relies on questionnaires and scales. That the unique experience of individuals is far from exhausted by a menu-driven, list-making orientation towards their inner subjective experiences.
But, Schreber’s account is not merely relevant as description of phenomena but his attitude to his verbal hallucinations is also instructive. See below:
I noticed therefore with interest that according to Kraepelin’s TEXTBOOK OF PSYCHIATRY (5th edition, Leipzig, 1896, p 110 ff) which had been lent to me, the phenomenon of being in some supernatural communication with voices had frequently been observed before in human beings whose nerves were in a state of morbid excitation. I do not dispute that in many of these cases one may be dealing with mere hallucinations, as which they are treated in the mentioned textbook. In my opinion science would go very wrong to designate as “hallucinations” all such phenomena that lack objective reality, and to throw them into the lumber-room of things that do not exist.
Science seems to deny any reality background for hallucinations…In my opinion this is definitely erroneous, at least if so generalised.
What one sees in Schreber is a surprising objectivity with regard to descriptions of abnormal phenomena. This requires a high degree of capacity for monitoring his internal life, standing back sufficiently to describe it, and retaining an objectifying stance that includes critically reading Kraepelin and rejecting his views. This is the enigma of schizophrenia: selective disordered thinking in the context of otherwise normal attitudes. Some people have called this ‘double orientation’. A patient of mine told me of how he was visited, nightly, by aliens in space crafts that could move through the solid walls and roof of his house. He believed this with extraordinary conviction but was also able to say that if someone else had recounted the same experience to him, he would regard it as evidence of madness. But, in his case it was true and not imagined!
Gilberto di Petta at the recent European Psychiatric Association conference in Nice likened psychotic experiences to addiction on drugs. He made the point that successfully treating these psychotic symptoms left a void in people’s lives, that the psychotic experiences had nostalgic value, and that these experiences are craved for. This argument is not novel but it is worth repeating. Schreber’s account shows how much emotional effort and personal time he had invested in thinking about and analysing his abnormal experiences. Treating Schreber successfully would need to include treating his experiences with respect.
This point is often lost on clinicians. John Nash whose life was described in The Beautiful Mind (biography and film) said
At the present time I seem to be thinking rationally again in the style that is characteristic of scientists. However this is not entirely a matter of joy as if someone returned from physical disability to good physical health. One aspect of this is that rationality of thought imposes a limit on a person’s concept of his relation to the cosmos. For example, a non-Zoroastrian could think of Zarathustra as simply a madman who led millions of naïve followers to adopt of ritual fire worship. But without his “madness” Zarathustra would necessarily have been another of the millions or billions of human individuals who have lived and then been forgotten’
The proper subject of psychiatry is the person, not the disease or indeed the concept that we reify.