hallucinations | NBB in Paris

While difficult, trying to retroactively diagnose Vincent Van Gogh was by far my favorite journal prompt. My group and I eventually decided that, based on the evidence we examined, Van Gogh most likely had schizophrenia. The Diagnostic and Statistical Manual of mental disorders (DSM-5) is a list of psychiatric conditions and their symptoms that helps professionals diagnose patients. It includes criteria to help diagnose schizophrenia today. For symptom-based identification it instructs that schizophrenia patients are expected to exhibit catatonic behavior, negative symptoms, delusions, disorganized speech, and hallucinations (American Psychiatric Association, 2013). Van Gogh showed many of these symptoms but the one that most clearly pointed to schizophrenia was his hallucinations.

According to the note from the Director of the St Rémy mental home, Vincent Van Gogh exhibited both visual and auditory hallucinations (Van Gogh Museum, 2016). The importance of hallucinations in both his life and the diagnosis of schizophrenia made me wonder about their underlying biological mechanisms. I was particularly intrigued by the idea that patients sometimes hear voices talking to them when no one else is there. The idea of “hearing voices” may be familiar from Hollywood’s portray of mental illness, but what actually drives these hallucinations?

In the scientific community, this phenomenon is known as auditory verbal hallucinations. One major theory is that these hallucinations are a result of malfunctions in the brain systems that monitor inner speech. This idea is that, when these brain systems are impaired, people misinterpret their own internal dialogue as the speech of someone or something outside of them (Catani and Ffytche, 2005). While this theory has been around for decades, there are still many unanswered questions about the specific biology and brain areas that are associated auditory verbal hallucinations.

Auditory verbal hallucinations are when patients
believe they hear voices speaking to them

A recent study by Cui et al. investigated the neuroanatomical differences that may be connected to this type of hallucination. The authors studied healthy control patients as well as a large population of schizophrenia patients who did and did not exhibit auditory verbal hallucinations from hospitals across China. The patients they gathered is an important aspect of this study because previous work had only compared schizophrenia patients with hallucinations to healthy controls. Here, the researchers wanted to specifically investigate what neuroanatomical difference leads to auditory verbal hallucinations, so it was important for them to look at schizophrenia patients that did not experience these hallucinations as well as those that did.

Once the authors had gathered this group of patients and controls, they used a magnetic resonance imaging (MRI) scanner to get a structural image of the subjects’ brains. They then used a computer software program to compute the thickness of the subjects’ cortex, the brain’s outer layer.In particular, these researchers were interested in measuring and comparing the thickness of the middle temporal gyrus (MTG).

The middle temporal gyrus (MTG)

Previous scientific studies have indicated that the MTG may be important for the monitoring of inner speech and is often less activated in schizophrenic patients (Shergill et al. 2000; Seal et al. 2004). The function and development of the MTG is well-suited for it playing a role in auditory verbal hallucinations. First, the MTG is involved in brain pathways that make it important for interpreting certain sounds we hear, especially processing language (Cabeza and Nyberg, 2000). The MTG is also unique in the way it develops. This area of the brain develops relatively late in life (Gogtay et al. 2004). This makes sense for hallucinations associated with schizophrenia, which is a disease known to be associated with brain development that often doesn’t appear until patients are around 30 years old (Lewis and Levitt, 2002).

Previous studies had shown that the volume of the MTG is smaller in schizophrenic patients than it is in healthy people (McGuire et al., 1995). The point of this study was to test if that reduced size was associated with schizophrenia in general or auditory verbal hallucinations specifically. When Cui et al. calculated the volume of the subjects’ middle temporal gyrus they found that it was significantly smaller in schizophrenia patients that had auditory verbal hallucinations than patients that did not. They also found that there was not a significant difference between the schizophrenia patients that did not have hallucinations and the healthy controls. These results suggest that a thinner MTG is not only connected to schizophrenia but is specifically associated with schizophrenia patients that experienced auditory verbal hallucinations.

Starry Night, a famous Van Gogh painting some
believe is the result of his hallucinations

While this new study offers great evidence comparing schizophrenia patients with different symptoms, there is still a lot to figure out about this kind of hallucination. Scientists are still working to discover what exact processes lead to cortical thinning and how those processes begin. However, what we do know about auditory verbal hallucinations emphasizes how heavily we rely on our perception of the world around us. We will not ever get to know the thickness of Vincent Van Gogh’s MTG, but the auditory hallucinations Van Gogh experienced were probably the result of his hearing system malfunctioning in some way. Today, many people believe that some of Van Gogh’s most famous decisions and artworks were informed by his hallucinations (Jones, 2016; New York Times Archive, 1981). Modern neuroscience tells us that those hallucinations may have actually been an erroneous interpretation of his own inner dialogue all along.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Binney RJ, Parker GJ, Ralph MAL (2012). Convergent connectivity and graded specialization in the rostral human temporal lobe as revealed by diffusion-weighted imaging probabilistic tractography. Journal of Cognitive Neuroscience 24, 1998–2014.

Catani M, Ffytche DH (2005). The rises and falls of disconnection syndromes. Brain 128, 2224–2239.

Cabeza R, Nyberg L (2000). Imaging cognition II: an empirical review of 275 PET and fMRI studies. Journal of Cognitive Neuroscience 12, 1–47.

Cui Y, Liu B, Song M, Lipnicki D, Li J, Xie S, . . . Jiang T. (2018). Auditory verbal hallucinations are related to cortical thinning in the left middle temporal gyrus of patients with schizophrenia. Psychological Medicine, 48(1): 115-122

Jones, J. (2016). Vincent van Gogh: Myths, madness and a new way of painting. Retrieved from https://www.theguardian.com/artanddesign/2016/aug/05/vincent-van-gogh-myths-madness-and-a-new-way-of-painting

Gogtay N, Giedd JN, Lusk L, Hayashi KM, Greenstein D, Vaituzis AC, Nugent TF, Herman DH, Clasen LS, Toga AW, Rapoport JL, Thompson PM (2004). Dynamic mapping of human cortical development during childhood through early adulthood. Proceedings of the National Academy of Sciences 101, 8174–8179.

Lewis DA, Levitt P (2002). Schizophrenia as a disorder of neurodevelopment. Annual Review of Neuroscience 25: 409–432.

McGuire PK, David AS, Murray RM, Frackowiak RSJ, Frith CD, Wright I, Silbersweig DA (1995) Abnormal monitoring of inner speech: a physiological basis for auditory hallucinations. The Lancet, 346(8975): Pages 596-600,

New York Times Archive (1981) Van Gogh’s Hallucinations. Retrieved from https://www.nytimes.com/1981/07/07/science/science-watch-van-gogh-s-hallucinations.html

Seal ML, Aleman A, McGuire PK (2004). Compelling imagery, unanticipated speech and deceptive memory: neurocognitive models of auditory verbal hallucinations in schizophrenia. Cognitive Neuropsychiatry 9, 43–72.

Shergill SS, Brammer MJ, Williams SCR, Murray RM, McGuire PK (2000). Mapping auditory hallucinations in schizophrenia using functional magnetic resonance imaging. Archives of General Psychiatry 57, 1033–1038

Van Gogh Museum (2016). Shortly before 27 February 1889 In Concordance, lists, bibliography (Documentation). Retrieved from: http://www.vangoghletters.org/vg/documentation.html

Images:

https://search.creativecommons.org/photos/71b807e7-29fd-445d-95a1-4d282ccf02e5

https://upload.wikimedia.org/wikipedia/commons/thumb/f/f5/Gray726_middle_temporal_gyrus.png/250px-Gray726_middle_temporal_gyrus.png

https://upload.wikimedia.org/wikipedia/commons/thumb/e/ea/Van_Gogh_-_Starry_Night_-_Google_Art_Project.jpg/757px-Van_Gogh_-_Starry_Night_-_Google_Art_Project.jpg

With 3 weekends having gone by already, I can easily say that this past weekend’s excursion to Provence was the most enjoyable one yet. The countryside in Provence was beautiful and the sights were breathtaking. From the Palais de Papes in Avignon to Pont du Gard to the city of Arles, this weekend gave me an enlightening glimpse into life in southern France. Earlier this week in class, I learned how Van Gogh spent the last years of his life in the Provence region, more specifically in the city of Arles. While in the city, I was able to visit the places around Arles that Van Gogh captured in many of his artworks. Van Gogh’s impressionistic paintings seem to have a life of their own, with golden strokes and dark blue swirls that seem to come right off the page. Standing in the same town that Van Gogh once called home and created masterpiece after masterpiece left me feeling in such a state of wonder. My state of wonder then began to stray away from the aesthetic aspect of his paintings towards pondering how did such a town inspire so many priceless works of art. I thought back to class when we discussed what Van Gogh’s life in southern France was like and the hardships he endured. Looking out over the Rhone, I began to ask to what level did Van Gogh’s mental state affect his work?

Actual location for the inspiration behind Van Gogh’s “La Nuit Etoilee”.

Amidst the beauty of these masterpieces lies hints toward the state of mind of Van Gogh. Surprisingly, many famous artists, inventers, composers, and the artistically creative show manic-depressive tendencies (Z. Janka, 2004). As discovered in class, Van Gogh was in fact plagued by many mental ailments, including hallucinations, seizures, night mares, insomnia, anxiety, manic episodes, depressive episodes, and alcohol abuse. One of Van Gogh’s most famous pieces, “Starry Night”, is thought to be inspired by a hallucination as he was admitted to a mental asylum at the time with no view of the cityscape accessible to him. Based on his reported behavior and mental ailments, I would most likely diagnose Van Gogh with bipolar disorder. Bipolar disorder is characterized by the National Institute of Mental Health as manic and depressive episodes that can be accompanied by psychotic symptoms (hallucinations and delusions) as well as substance abuse (NIMH). Approximately 15% of those with bipolar disorder have visual hallucinations and 28% have auditory hallucinations (F. Waters et al., 2014). The notion that multiple of Van Gogh’s artworks may have been a result of a hallucination intrigued me, as his paintings appear highly vivid, rich in color, with realistic yet whimsical details. Upon investigation into the neural mechanisms behind hallucinations, I learned that there are multiple ways that neurocircuitry plays a role in producing hallucinations.

When a sensation is perceived, let’s say a visual sensation, information from that sensation is sent from the retina to the visual cortex (V1). This is called bottom-up processing. When the brain first perceives a stimulus and then uses previous knowledge to influence what you are perceiving, it is known as top-down processing (A. Engel et al., 2001). A popular theory to the occurrence of hallucinations faults failures in either top-down or bottom-up processing that results in a perceptively false experience (L. Zmigrod et al., 2016). In psychiatric disorders such as bipolar disorder and schizophrenia, signals between top-down and bottom-up processing may become tonically hyperactive, causing top-down sensory expectations that result in false conscious experiences, otherwise known as a hallucination (S. Grossberg. 2000). Another theory behind the manifestations of hallucinations focuses more strongly on bottom-up processing. When visual hallucinations occur, there is heightened activity in secondary and association visual cortices, the occipital lobe, and in visual processing areas in the parietal lobes. This hyperactivation of different brain regions may cause over-perceptualization which results in a change in activity in areas such as the prefrontal or premotor cortices, allowing for individuals to have a false sense of agency and perceive their own internal auditory or visual activity as “vivid external percepts” (L. Zmigrod et al., 2016). Either way, these false senses of stimuli or experiences cause an individual to perceive a false reality, hallucinating visual or auditory experiences and believing them to be authentic.

Diagram comparing top-down processing to bottom-up processing

Even given Van Gogh’s medical history, his personal account of his struggles, accounts from people who interacted with him, it is still difficult to fully understand the impact that his mental/physical health had on his work. Was “Starry Night” a complete illusion? Did Van Gogh cut off his ear due to an auditory illusion? While we may never know the true answers to the questions, we can still infer that Van Gogh was, at the least, influenced by his possible bipolar disorder and the hallucinations that may have accompanied it.

Map of Arles, France

Works Cited

Engel, A. K., Fries, P., & Singer, W. (2001). Dynamic predictions: oscillations and synchrony in top–down processing. Nature Reviews Neuroscience, 2(10), 704.

Grossberg, S. (2000). How hallucinations may arise from brain mechanisms of learning, attention, and volition. Journal of the International Neuropsychological Society, 6(5), 583-592.

Janka, Z. (2004). Artistic creativity and bipolar mood disorder. Orvosi hetilap, 145(33), 1709-1718.

NIMH: Bipolar Disorder. (n.d.). Retrieved from https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

Waters, F., Collerton, D., Ffytche, D. H., Jardri, R., Pins, D., Dudley, R., Larøi, F. (2014). Visual hallucinations in the psychosis spectrum and comparative information from neurodegenerative disorders and eye disease. Schizophrenia bulletin, 40 Suppl 4(Suppl 4), S233–S245. doi:10.1093/schbul/sbu036

Zmigrod, L., Garrison, J. R., Carr, J., & Simons, J. S. (2016). The neural mechanisms of hallucinations: a quantitative meta-analysis of neuroimaging studies. Neuroscience & Biobehavioral Reviews, 69, 113-123.

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