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Home , Hallucination, Tactile hallucination

J Neurol Neurosurg : first published as 10.1136/jnnp.45.4.285 on 1 April 1982. Downloaded from

Journal ofNeurology, Neurosurgery, and Psychiatry 1982;45:285-293

Occasional review Tactile : conceptual and historical aspects

GE BERRIOS From the Department ofPsychiatry, University of Cambridge Clinical School, Addenbrooke's Hospital, Cambridge, UK

SUMMARY A brief historical analysis of the general concept of is presented and the suggestion is made that it emerged as the unwarranted generalisation of a perceptual model that was meant to apply only to vision and the "distance ". Against this background the evolution of tactile hallucinations is considered and its interaction with 19th century psychological theory explored. It is concluded that tactile hallucinations are sui generis phenomena which do not fit the conventional model and whose clinical identification rests on criteria so far unclear. A brief review of their taxonomy and diagnostic usefulness is presented. Some wider implications are drawn which should be relevant to the general concept of hallucination. Protected by copyright.

The of touch, although rich and substance. In addition to extension he maintained complex, has become subordinated, in current all bodies possess the fundamental quality of psychiatry, to other symptoms and no longer "solidity". He acknowledged therefore "solidity" commands descriptive or diagnostic interest. This as "the idea most intimately connected with and may reflect both its relative clinical infrequency essential to body, so as nowhere else to be found or and a secular uneasiness concerning its conceptual imagined but only in matter". (II, IV, 1) This idea status. "we receive by our touch: and it arises from the Touch has been, since Greek times, a reluctant resistance which we find in body to the entrance of "fifth ". Aristotle' considered it as a primitive any other body into the place it possesses, till it perceptual system (423.b.12) and remarked upon has left it". (II, IV, 1) the fundamental characteristic that sets touch apart The epistemological inquiry into what are the from the "distance" senses: "But there is a dif- bodily components that suggest the idea of solidity ference between the object of touch and those of led to the identification of "feelings of resistance" http://jnnp.bmj.com/ sight and , since we perceive them because the and "motor sensations" which conveyed superior medium acts upon us while we perceive objects information to "mere feelings". Armstrong3 has of touch not through the agency of the medium but expressed this thus: "For all forms of sense per- simultaneously with the medium, like a man who is ception besides seeing, hearing, tasting and smelling struck through his shield". (423.b.12) we employ the word feeling.. . nevertheless it will This view remained unchanged until the 17th be convenient to distinguish between at least two century when British empiricism developed an sorts of sense covered by the word interest in the epistemology of touch. For example "feel": perception by touch and perception of our on September 29, 2021 by guest. Locke2 rejected the Cartesian view according to own bodily state".3 This distinction was introduced which extension constitutes the essence of material in psychology by Weber4 as "Tastsinn" (touch) and "Gemeingefuihl" (common sensibility). These two Address for reprint requests: Department of Psychiatry, categories provided late 19th century psychiatrists Level 4, New Addenbrooke's Hospital, Hills Road, Cam- with a conceptual framework to describe and classify bridge CB2 2QQ, UK. clinical phenomena as widely apart as tactile hal- Received 12 September 1981 lucinations, neurasthenia, coenesthopathy and deper- Accepted 1 November 1981 sonalisation. 285 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.45.4.285 on 1 April 1982. Downloaded from

286 Berrios

THE GENERAL PROBLEM the case, how does it apply to ? The current conceptual model of hallucination How is a real to be distinguished from a hal- developed during the early 19th century out of the lucinated one if in neither case the presence of an analysis of vision.5 Of the original cases reported object in public space is required? Are perhaps by Esquirol,5 five had visual hallucinations. He hallucinations of touch different in a fundamental commenced his paper by claiming: "If a man has way from those occurring in the "distance senses"? the intimate conviction of actually perceiving a This abstract distinction may or may not be sensation for which there is no external object, he clinically relevant. For example it can be said that is in a hallucinated state: he is a visionary ("vision- the "external object" criterion is unimportant for naire")"; and concluded "The hallucinations of the diagnosis of tactile hallucinations. Indeed it vision ... have been called visions but this term is can be said it is unimportant for the diagnosis of appropriate only for one perceptual mode. Who visual or auditory hallucinations in general. This dares to talk about auditory visions, visions, would be based on the observation that normally olfactory visions? ... But the functional alterations, psychiatrists do not search for the hallucinated mechanisms and the clinical context involved object in public space. It is on the bases of con- in these three senses is the same as in visions (my comitant symptoms, context, past history, and italics). A generic term is needed. I have proposed quality of reported hallucinatory experiences that the word hallucination. . ." (From now on the the diagnosis is usually made. If this is the case, author's translation unless otherwise stated.) This then it follows that the "perceptual" aspects of homogeneous treatment of all sense modalities hallucinations may not be, after all, that important. assumed they behaved conceptually in a symmetrical Since the 19th century perception-related concepts manner, for example that they obeyed the have been used at two levels in relation to hallucina- "causalist" paradigm (that is requiredforan"external tions: (1) descriptively as when patients' reports object" to impinge upon the sensors). This view about "seeing" or "hearing" things are taken at Protected by copyright. Esquirol received from Condillac.6 Therefore in face value and recorded as "perceptual data without generalising the definition of hallucination as a necessarily having a basis in reality", (2) aetiologi- "perception without object" he embodied as a cally as when it is concluded that because of the type logical requirement the absence of an external and of experiences, the patients concerned are actually public object. suffering from a "disorder of perception". The This symmetrical epistemology has remained first level is theory-neutral in that patients' reports can enshrined in the phenomenological psychopathology be taken as simply meaning that they "believe" that that we have inherited from the 19th century. It their perception is involved not committing the does not distinguish between, on the one hand, observer to assume that perception is "really" vision, audition and olfaction which have an "object" disordered (Esquirol took this line). The second in public space (whose existential status may be level, however, commits the psychiatrist to analysing consensually determined), and, on the other, the the patient's perceptual apparatus as it assumes that rest of bodily sensations, to some of which the perceptual hardware is actually disrupted. classical model does not seem to apply. Warmth, pressure, and vibration seem in ordinary HISTORICAL BACKGROUND circumstances to be related to external agencies and The view that all manner of hallucinations are http://jnnp.bmj.com/ therefore are open to consensual appraisal; they can fundamentally disorders of perception has been be said to fit the "causal" model. But sensations predominant since early last century. The distinction such as aches, , , twitches, tickles etc between "organic" and "functional" hallucinations depend essentially upon being "felt" and their started in the 1850's and created as many problems reality therefore is not logically connected to external as it solved. It originated from the confluence of agencies; hence the subject's report is in normal the two reigning psychologies during this period: circumstances accepted unchallenged. whilst Associationism supported the analysis of The actual criteria for ascertaining the presence mental experiences into discreet units, Faculty on September 29, 2021 by guest. of hallucinations in clinical practice are complex Psychology guaranteed the autonomy of perception. and have not yet been fully worked out in the For example the notion of "" literature. Features such as bizarreness of content was used from Hagen to Kandinsky7 to cope and context, concomitant cognitive state, behavioural with the clinical anomalies that fitted neither the signs, absenceof external object may all be important. organic nor functional categories. It is unfortunate Theoretically the latter would seem crucial as it that Jaspers'8 idiosyncratic interpretation of Kan- follows logically from the very definition ofhallucina- dinsky led to the official view that pseudohallucina- tion as a "perception without object". If that were tions constitute a "third" class. This anachronistic J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.45.4.285 on 1 April 1982. Downloaded from

Tactile hallucinations: conceptual and historical aspects 287 conclusion neglects the fact that Kandinsky wrote appealed to by reason to correct the other senses may in the context of an ongoing debate on hallucina- also deceive the insane .., he may hallucinate rough tions and that his intention was to provide a rag-bag surfaces or sharp ends hurting his skin, he may feel for unclassifiable hallucinatory experiences. Be torn apart by cutting instruments". Sigmond18 that as it may, the so-called defining criteria for observed that "hallucinations of touch vary exceed- do not apply to the tactile sense ingly; it is singular enough to find an individual where the questions of insight and external space who believes that he has rats crawling over him, do not arise. The view of hallucination as a sym- that spiders infest him. . ." Griesinger19 made the metrical and homogenous disorder in all five senses fundamental observation that in touch "hallucina- breaks down in relation to the impossibility of tions and cannot be distinguished from each "pseudohallucination" occurring in some sense other; or rather the phenomena which constitutes modalities (that is, touch). them, so far as they do not depend on anaesthesia, Since the 19th century national psychiatries have are in every case to be considered as illusions because responded to these difficulties according to local the specific anomaly consists in the false interpreta- philosophies and etymologies. For example French tion of certain sensations" (my italics). and German psychiatry have drawn a less vigorous Brierre de Boismont20 stated "it is said that hal- line between hallucinations and than the lucinations of touch are difficult to investigate British. "Delire" and "Wahn" (the French and because they are apt to be confounded with neurolo- German terms for "" respectively) have a less gical affections... there can be no question that "intellectualistic" orientation than the English there are some hallucinated persons quite capable of term "delusion".9 Furthermore they assume a judging correctly of their sensations". Brierre disturbance of personality and a fracture in the therefore believed that on physical examination "relationship" between the subject and his world there was nothing neurologically wrong with patients that is lacking in the English "delusion" ordinarily experiencing tactile hallucinations. Tuke2' did not Protected by copyright. defined as wrong or pathological "belief", that is, separate tactile from internal or corporal hallucina- as a disorder of thinking. tions and included under "tactile hallucinatory Hallucinations therefore tend to be considered in experiences" experiences such as "electrical shock", continental psychiatry as a subset of delusions "delusion of being changed or Lycantropy" and (thatis, "sensory delusions") and hence less emphasis "sexual hallucinations". Storring22 included all is put upon their "perceptual" than upon the these under "hallucinations of the cutaneous sense": "cognitive" or "apperceptual" aspects.-0 11 In "In tremens patients often have hallucina- opposition to this, the "intellectualistic" view of tory sensations of spiders creeping over their skin, madness that Locke sponsored is still recognisable of ants running over them or of being covered by a in British views on both delusion and hallucination. fur." He also included more complex experiences "they frequently complain of electrical currents TACTILE HALLUCINATIONS traversing their bodies. Others feel as if they were Books on descriptive psychopathology are singularly beingkissed, or as if someone were lyingby their side". reticent about tactile hallucination;12-16 and Ey's When writing on "morbid tactile sensations" "Traite" dedicates to them only 16 pages (out of Kraepelin23 included , bizarre sexual 1543). This may reflect their clinical and statistical experiences and complex movement experiences http://jnnp.bmj.com/ unimportance but also their confused conceptual involving the body of the patient. He stated that status. Descriptions of "imaginary itches" are "not frequently these , connected found in earlier literature. Darwin17 reported a case apparently with organic sensations, receive a very with imaginary diabetes who experienced "a hal- strange interpretation . ." and "as the result of lucinated idea (an itch) so powerfully excited that these hallucinations the conviction is often developed it was not to be changed suddenly by ocular sensa- in the patients that they have become the sport of all tion or reason". During the 19th century clinical sorts of influence". Bleuler24 carefully separated descriptions of tactile hallucinations are found bodily from tactile hallucinations, dedicated a long on September 29, 2021 by guest. associated with four clinical areas: ; com- section to the former and of the latter wrote: plex, non-psychotic somatic abnormal experiences "tactile hallucinations are rare (in ) ... (for example coenesthopathies); organic and toxic occasionally patients complain of small animals, ; and the developing concept of "delu- particularly snakes, crawling over their bodies". sional parasitosis". TACTILE HALLUCINATIONS AND TACTILE HALLUCINATIONS AND THE INSANITIES COENESTHOPATHY Esquirol5 in a Lockean vein wrote "touch, often This French syndrome25 reflects well the earlier J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.45.4.285 on 1 April 1982. Downloaded from

288 Berrios

German conceptual distinction between skin senses TACTILE HALLUCINATIONS AND ORGANIC (Tastsinn) and common feeling (Gemeingefuhl).4 AND TOXIC SYNDROMES "Gemeingefiihl" refers to the remaining corporal After the development of "Haptics" by Dessoir in sensations once those associated with the skin 189234 touch was considered less and less as a (that is, touch, temperature, pressure and location) monolithic fifth sense. Dessoir had divided haptics are separated off. They constitute a heterogenous (which was to touch what "optics" was to vision) array such as and "objectless" sensations such into "contact sense" and "pselaphesia", correspond- as well-being, pleasure, , shudder, hunger, ing roughly to passive and active touch respectively. nausea, organic muscular feelings etc. . . This group Movement and "motor sensations" were identified was also called coenesthesia26 and some workers as characterising active touch and provided the speculated that they provided the experiencing crucial conceptual distinction in Dessoir's classifi- subject with his "sense of existence".27 cation.35 36 This was well expressed by Merleau To explain the origin of this unified bodily feeling Ponty37 "movement of one's body is to touch what two theories were put forward. Associationism lighting is to vision... There are tactile phenomena, stated that coenesthesia resulted from the summation alleged tactile qualities, like roughness and smooth- of propioceptive and interoceptive sensations ;28 ness which disappear completely if the exploratory Faculty psychology on the other hand postulated the movement is eliminated". Active touch continues existence of a hypothetic brain centre or function being treated as a separate category.38 on which all sensations converged; the resulting Hallucinatory experiences pertaining to active somatognostic pattern consisted in a dynamic touch are clinically very rare but occasionally "Gestalt" type of account of the position of the sensorial transformations from active touch to body in time. It provided the basis for vision have been reported as the case of a blind notion of "body schema". patient who hallucinated visually in Braille code.39 Tactile hallucinations and indeed tactile distortions Protected by copyright. Soon after itsinception, however, thepsychological of all kinds (that is, pins and needles) are therefore territory of coenesthesia underwent gradual erosion more common in passive touch. This was recognised as sensations such as hunger, thirst, sexual pleasure by Regis40 "hallucinations in active touch are etc were separated off. In the end all that was left rare . . . this is not so in passive touch where they were sensations, common to various organs, such manifest themselves as skin sensations such as as deep pressure, pain or unanalysable sensations formication, pinching, rubbing, crawling etc". such as "tickling" or "stuffiness".29 Paraesthesiae and itches may be reported directly It is at this stage that the concept of "coenestho- or obliquely. Direct reporting by subjects otherwise pathy" developed in French psychiatry.25 It was normal tends to be considered as unobjectionable defined as "local alteration of the common sensibility and not resulting from psychopathology. Oblique in the sphere of general sensation, corresponding reporting, on the other hand, making use of analogi- to hallucinosis in the sphere of sensorium".25 cal "as if" descriptions, can be met with in derma- A "painful" and "paraesthetic" type of coenestho- tological practice. For reasons which are so far pathy were recognised and each classified as having unclear, the "as if" qualification may occasionally be abandoned by the patient and replaced by a

a cephalic, thoraxic or abdominal localisation. http://jnnp.bmj.com/ Patients in the former group might feel their organs delusional interpretation. In these cases the psychia- being "stretched, torn, twisted" etc or they might in trist is more likely to intervene. The natural history, the latter group experience itching, hyperaesthesiae, incidence and mechanisms for these transitions is paraesthesiae etc. unknown although its clinical existence has been known for a long time. Griesinger19 in a superb This was never accepted in Anglo- description writes: "the commencement of these Saxon psychiatry and the symptoms it referred to delusions consists in certain painful sensations were recatalogued as hypochondriasis, neurasthenia, being merely phantastically compared (my italics) or dysmorphophobia.30 In France itself some by the patient to analogous phenomena. Therefore on September 29, 2021 by guest. coenesthopathies, for example "topalgie" (or cephalic hypochondriacs at first say only that it seems to cenestopathy) were later on included in alternative them as if serpents crawled over their skin . . . but diagnostic categories such as "neurovegetative the prolongation of the sensations, the influence dystonias",31 "subjective disorders of sensibility" of unfavourable external circumstances, an increas- associated with "psychoneuroses"32 or simply ing internal disharmony... the patients soon begin to psychosomatic syndromes.33 Some French psychia- consider the matter more earnestly, the comparison, trists continue studying these phenomena under the at first imaginary, becomes a fully developed general rubric of "disorders of corporal scheme".31 delusion. . ." J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.45.4.285 on 1 April 1982. Downloaded from

Tactile hallucinations: conceptual and historical aspects 289 But this is not always the case. In some cases their skin. Clerambault45 elegantly described these the "as if" qualification is never dropped and chronic as hypodermic, distal and punctiform hallucinations, hospital attendance and complicating affective and believed they were often accompanied by disorder redefine the problem as psychiatric. In "sensations of movement" and by involvement of others, the "as if" qualification is actually never . Chloral tactile hallucinations produce present; instead the delusional account appears feelings of "humidity" over the skin but are not from the start with the hallucinatory or sensory accompanied by "kinetic" sensations. In general component playing a minor role. Once the transition chloral hallucinations are more superficial, accom- from the "as if" to the delusion has taken place it panied by pain and experienced in the interdigital becomes difficult to separate the delusional elabora- folds." Tactile hallucinations following intoxication tion from the raw sensory experience. It is possible by Atropa Belladona were described by Moreau de that the cognitive distortion resulting from the Tours46 who reported a case who felt "that millions delusion may act as a new source of experience; of were devouring his head". as it occurs, for example in the so-called "sympathy These states have been classically likened to phenomenon" in which itching (or other sensations) feeling ants crawling under the skin. The generic may be experienced by the observer in the same area terms coined to describe these sensations were of skin where he has just witnessed someone else Psora Imaginaria, "Imaginary itch"'17 and formi- hurtinghimself.Henceitis possible that the persistent cation. The last mentioned term had been used in belief of having insects under the skin (for example, general medicine at least since the 16th century ) may generate skin sensations when Ambrosio Pare took advantage of its meta- (or changes) that in turn confirm and perpetuate the phorical value and described "pouls formicant" delusional belief. (formicant pulse) as "a weak, frequent pulse that The model for tactile hallucinations has been gives the sensation of 'crawling like an ant' ".47 provided for over a hundred years by the tactile The earliest reported usage in dermatology occurred Protected by copyright. experiences characterising and in 1707 ;48 by the 19th century it was well established intoxication. The problem with the former not only in relation to but to is that it tends to occur in the context of clouded any condition where "there was a disagreeable consciousness and is compounded by visual hal- creeping sensation in the skin". lucinations and discreet delusional interpretations. Tactile hallucinations associated with organic Cocaine "haptic" hallucinations, on the other hand, states other than -induced have also been may occur in clear consciousness and this makes described in the literature such as brain injury;49 them particularly suitable for phenomenological dementia;50-52 hypophyseal tumour;53 diabetes.54 analysis. Classical writers also described "chloral" In her sample of 46 cases with delusions of infesta- and atropinic tactile hallucinations in detail. tion Skotts5 found that about 50% exhibited clinical Up to 15 % of those using cocaine for "recreational signs of an "organic brain syndrome"; 61 % had purposes" may report tactile hallucinations.41 pathological EEGs; and 12% had malignant However, individuals in Siegel's sample consumed (for example, carcinoma of cervix, breast, at least 1 gram of cocaine a month for 12 months. colon, lung etc). Berrios (unpublished observation) The early literature states that cocaine by injection has recorded one case of facial tactile hallucinations is more likely to produce tactile hallucinations.42 associated with hypophyseal tumour and another http://jnnp.bmj.com/ More recently it has been reported that it may also of delusional parasitosis associated with mediastinal cause a reduction in tactile sensibility.43 Tactile lymphoma. hallucinations may appear after six months of persistent use and in the wake ofvisual hallucinations. TACTILE HALLUCINATIONS AND Prodromal feelings are itching of hands, legs and "DELUSIONAL PARASITOSES" back; "moving itches" follow accompanied by Females of middle age (or older) without history "as if" interpretations (for example "insects" or of drug intoxication occasionally complain of "people brushing past"). According to Siegel41 parasites on or under the skin to health inspectors on September 29, 2021 by guest. none of his patients "believed that insects or or dermatologists and less often psychiatrists. objects were actually present, although they would Insects, maggots, bugs or other non-descript little often scratch or rub the skin" (my italics). He animals live, breed and burn holes in their skin. concludes therefore that these experiences were Patients sometimes may date the onset of this to "pseudo-hallucinations". having moved into a new house and very rarely Classical writers, however, considered these to other family members share their belief. Patients be true hallucinations. Magnan and Saury44 describe may sometimes also "see" the bugs and produce how their patients tried to remove bugs from under as evidence for their existence bottles containing skin J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.45.4.285 on 1 April 1982. Downloaded from

290 Berrios detritus, fluff etc. visual hallucinations in the elderly, with some writers The clinical and therapeutic aspects of this claiming that they are always associated with syndrome have been well dealt with in recent organic or functional psychoses or visual cataract literature and are beyond the scope of this paper and others sustaining that they can be the only (for a complete review see Skott55). Conceptual symptom present.64 hesitations however punctuate the history of the As opposed to the "sensorialist view" others syndrome and illustrate well difficulties involved in defended a cognitive approach according to which the notion of tactile hallucination itself. the syndrome was primarily delusional. Dupre65 The early description of the syndrome as "itchy described a "delire de zoopathie interne" and his dermatoses" ;56 "acarophobia"57 and "parasito- disciple Levy sub-divided it into "internal" and phobia"58 suggested amongst later writers the "external" types. The primary feature in these anachronistic impression that the syndrome in the syndromes being the delusional belief (delire) of late 19th century was actually considered as harbouring animals in or on the body. The 29 cases 4"phobia" or "". The concept of "phobia" he described involved rats, birds, worms, snakes at the time however was not yet related to the etc but no insects are mentioned. Faure et a166 neuroses; indeed it was just undergoing a semantic in turn described two cases where "le delire zoopathi- transformation to separate itself from the cognate que" concerned insects and iterated the view that notions of obsession and delusion. These three the fundamental problem was "delusional" in notions were contained in the common parent nature. Wilson and Miller67 suggested the term concept of "fixed idea" which had been used by "delusion of parasitosis" and favoured their earlier writers to refer to the central symptom of delusional origin; their phenomenological analysis insanity. For example Perrin58 considers his "para- however is unsatisfactory. A few years later Wilson68 sitophobia" to be generalised, hallucinatory, con- went on to state that these "delusions" could even tinuous and unaccompanied by or other occur in "psycho-neurosis". Protected by copyright. affective disturbance. This writer remained undecided Bers and Conrad69 in a classical paper put forward as to what the primary disorder was in these cases, the notion of "chronic tactile hallucinoses" but thus starting the that to this day character- took an intermediate position as they found it ises the interpretation of this syndrome. On the difficult to decide what was "primary" and what was one hand he mentioned "profound alteration of "secondary". This hesitation, however, must be intellectual faculties" expressing itself in a "fixed understood against the context of Professor Conrad's idea" (that is, having a delusional origin). On the "Gestaltic" view of delusions70 and of the history other, he considered "hallucinations" (that is, of the concept of "Hallucinoses" in German sensory changes) as crucial to the syndrome. psychiatry. Bers and Conrad suggest that a sensorial Subsequent writers developed either of these disorder is sometimes relevant, but feel that in options and the many names they coined show their general, "chronic tactile hallucinosis" must be based theoretical preferences. Some believed the primary upon a delusional state, this being, like any other disorder to be a tactile hallucination or chronic hallucinosis, accompanied by hallucinations (or even a real sensation) with the delusional which are analogous71 72 to those that can emerge interpretation following on (that is the mechanism that Griesinger had suggested). MacNamara59 wrote in schizophrenia-prone personalities.73 Evidence http://jnnp.bmj.com/ "hallucinations .., constitute its most outstanding that the incidence of schizophrenia may be higher characteristic". Mallet and Male60 in an oft quoted in families of patients with delusional parasitosis but rather unimpressive paper considered "haptic is however not available. Nonetheless Skott55 hallucinations" as the primary feature. Others felt has found that siblings of patients with delusions of that the perceptual component was indeed primary infestation have significantly more psychiatric but not necessarily "hallucinatory" in nature. For morbidity than controls (p < 0-01). Whether or example Gamper6' suggested an organic basis not this was related to schizophrenia is not specified. for the primary itch. Schwarz62 pointed out that The British position has been to consider these on September 29, 2021 by guest. the syndrome may follow abnormal skin sensations states as fundamentally delusional in nature.30 74-78 occurring early in depressive illness. Ekbom49 This has recently been given some support by Skott55 believed that presenile paraesthesiae were at the who concludes that the "psychiatric symptomatology basis of his "Preseniler Dermatozoenwahn". (in delusional parasitosis) is extremely varied ... Harbauer,50 Fleck,63 Liebaldt and Klages53 also patients may suffer from illusions, misconceptions supported the view that primary organic, sensory and delusions and in rare instances hallucination". pathology was at the basis of the disorder. A similar The syndrome has therefore become independent of interpretation has been followed in relation to the presence of primary tactile hallucinations. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.45.4.285 on 1 April 1982. Downloaded from

Tactile hallucinations: conceptual and historical aspects 291 CLASSIFICATION OF TACTILE by insight) and non-delusional hallucinatory HALLUCINATIONS experiences. The latter referred to hallucinations Tactile hallucinations may be classified according to proper in which the delusional (delire) component phenomenological or clinical criteria. The former is constitutes the morbid core thus reflecting a severe theoretically important in that it may suggest a dislocation in the relationship between the subject descriptive basis to separate hallucinations from and his world. delusions, for example by distinguishing "pure" from "interpreted" hallucination. Descriptions of Conclusions ''pure" hallucinations concentrate on the raw sensation, for example itches or aches reported During the early 19th century all manner of "per- without delusional interpretation. The clinical ceptions without object" were brought together existence of these "pure" states, however, is called by Esquirol under the common denomination of into question by the view that since all hallucination. This term had, until then, been mainly hallucinations are by definition disorders of related to vision, that is to a "distance sense". The perception (and not of sensation), they a fortiori conceptual model it generated, therefore was only include a cognitive, interpretative component.'0 applicable to vision, audition and, to a lesser In practical terms, therefore, it could be said that extent, to smell and taste. "pure" hallucinatory experiences do not exist A number of tactile hallucinatory experiences have and that those described as such are hallucinations always remained outside the epistemological with a "reduced" or "concealed" delusional inter- boundaries of the conventional model. They seem pretation. to be sui generis psychopathological phenomena that Tactile hallucinations, whether associated with only superficially resemble hallucinations in the functional psychoses, drug intoxication, other distance senses. organic states and delusional parasitosis tend to be The problem therefore is how they are recognised Protected by copyright. found in clinical practice accompanied by evident in clinical practice. It is suggested that criteria and often vivid delusional interpretation (for example such as consensual agreement on absence of public itches are reported as the crawling of ants). Diffi- , quality of actual morbid percept, and culties in separating on purely phenomenological relationship of this percept to contextual field of basis "real" from "illusory" or "hallucinated" normal perception are not relevant to the diagnosis itches have led writers to resorting to a rough of tactile hallucinations. Indeed this analysis suggests assessment of the quality and extent of the accom- that these three criteria (derived from the causalist panying delusion (and resulting behaviour) as a model of perception) are not relevant to the recogni- means for differential diagnosis. tion of any form of hallucination. Clinical classifications, on the other hand, are Empirical analyses of the decisional tree adhered more factual but their diagnostic value is equally to by clinicians in the diagnosis of hallucinations doubtful. Classical writers (for example Magnan, are unavailable. Concerning tactile hallucinations Saury, Clerambault) provided detailed descriptions it is concluded that in most situations the delusional of the tactile hallucinations accompanying the component seems to be an important diagnostic various toxic states and believed that they could be factor; namely rough assessment of delusional used for diagnostic purposes. No statistical evidence intensity, quality and influence upon behaviour. http://jnnp.bmj.com/ exists to support these early beliefs. Ey" classified Thence the possibility that the concepts of hal- "haptic hallucinations" into "thematic" and "athe- lucination and delusion may, in general, be far matic". Amongst the former he included hallucina- closer to each other than it has hitherto been consid- tions of "external" objects (for example animals on ered in British psychiatry, must be taken seriously. the skin, erotic contacts etc) and "internal" objects, This indeed seems to be the position taken by a the best example of which is the "internal zoopathy" number of French, German and Spanish psychi- (for example complaints of animals living under the atrists. skin or inside the body). "Athematic" tactile on September 29, 2021 by guest. hallucinations have no specific object and report References primary touch sensations such as pruritus, aches, cramps, tearing of the skin, feeling of wet, cold and Aristotle: De Anima, Books HI and III translated by hot. He also two "structural modali- Hamlyn, DW. Oxford: Clarendon Press, 1968. distinguished 2 Locke J. An essay concerning human understanding. ties" in these experiences: "Eidolie hallucinosiques" Fraser AC, ed. New York: Dover Publication, 1959. and "hallucinations delirantes tactiles". The former 3 Amstrong DM. Bodily sensations. London: Routledge referring to a group that includes pseudohallucina- and Kegan Paul, 1962. tions, localised organic hallucinations (accompanied 4 Weber EH. Der Tastsinn und das Gemeingefuhl. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.45.4.285 on 1 April 1982. Downloaded from

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