red light that he said wasn’t actually there. Commentaries I began to ask all my PD patients taking medications about their not see- ing or hearing things that they should have. About 30% reported frequently not seeing their spouse, the most com- Negative Hallucinations mon negative hallucination, or not hear- [April Fool’s] ing things, again, most commonly the  spouse. Many reported not seeing stop signs when driving, items at the super- Negative symptoms have attracted from positive and depression from nega- market or hearing the spouse ask them increasing attention in the study of schizo- tive emotional energy. to do errands, such as picking up items phrenia for the past 20 years. Hughlings The concept of a negative hallucina- at the market. Jackson first categorized neurological tion, however, was introduced in the psy- In studies outside of PD, negative phenomena into negative and positive choanalytic literature with a single paper hallucinations are very common, and have classifications a century ago. Positive published in the last issue of a standard a gender predominance in males, start- symptoms are generated by over-activity German analytic journal, closed by the ing in prepubescent boys, and increas- of a brain region, such as seizures, trem- Nazis. I see a lot of patients who have hal- ing. They are much more common in ors and other involuntary movements. lucinations since the drug treatment of married men than unmarried. The psy- Negative symptoms are generated by Parkinson’s disease (PD) causes halluci- chiatric literature distinguishes between under-activity of brain regions, as with nations in about 30%, and delusions in “positive amnesia” and “negative amne- stroke, brain tumors or other mass lesions about 10%. Sadly, I probably induce more sia.” This terminology is confusing be- or injuries producing weakness, reduced psychotic symptoms than any other single cause “negative amnesia” refers to memo- movement, aphasia or reduced sensation. doctor in New England. The hallucina- ries not made whereas “positive amnesia” Schizophrenia, to the unsophisticated tions are quite stereotypic. The drugs typi- refers to memories that have been sup- observer, produces odd behavior caused cally cause visual hallucinations of people, pressed. They have generally not been by hallucinations, delusions, loosened and animals or sometimes inanimate objects commented upon or much studied due illogical associations, all considered posi- such as trucks, cars and statues, that are to their overlap with inattention, the tive phenomena because they are addi- free of emotional content. However, a pre- confabulatory syndrome of minor tional, abnormal thoughts, whereas the viously unrecognized phenomenon in the memory failure (CSMMF), sometimes negative phenomena of reduced sponta- world of drug-induced hallucinations was called “CRS” (can’t remember sh__) in neity, reduced pleasure, reduced described to me by a patient. He told me the lay world, and outright lying (malin- thoughts, blunted emotions, reduced so- that he sometimes didn’t see things that gering). This wide differential diagnos- cial interactivity are considered negative really were there. He considered these hal- tic list makes epidemiological studies in- symptoms. Positive symptoms respond lucinations in reverse. He would see two accurate. In addition certain authorities much better to antipsychotic medica- people when three were visiting. He doubt the existence of negative halluci- tions, leaving the negative symptoms as would hear his children but not his wife nations. The issue has been brought be- the most disabling in schizophrenia, along even though he knew she was there and fore the Supreme Court, but the ques- with certain cognitive changes that have was yelling at him. The description was an tion of whether this explanation can be also not been amenable to therapy. One almost verbatim copy of the von invoked as a defense, has not been an- can obviously extend the same concept Fischenbach paper in Der Fortshreitten swered since the Court has ruled on very to bipolar disorder, with mania resulting Psychoanalatik. “I very clearly saw my two narrow grounds, carefully avoiding tak- adult sons, who were visiting from out of ing a stand on an issue not fully resolved Table. Differential diagnosis town. I then asked when their mother, my by psychiatrists. of negative hallucinations wife, was returning, which surprised them DSM V* RT 43b (Diagnostic and because she was standing with them.” Statistical Manual, Fifth revision, abbre- Amnesia Having never encountered this be- viated version, Revised Translation, 43 rd fore, I explored it with the patient and his rendition, b supplement) defines a nega- Inattention wife. She reported that he had been “ig- tive hallucination as a “suppressed per- Lying noring” her intermittently for many ception” of a clearly perceivable sensory months, ever since his last increase in a input that is due to synchronized over- Sensory impairment dopamine agonist. When we lowered the activity of the brain which is not epilep- Sensory overload dopamine agonist, he got stiffer and slower tic. It is deemed a “possible but not and preferred to be more mobile and not proven symptom.” Thus, a hearing-im- Conversion see his wife so much, so we increased it. It paired person would not have a negative was not clear that he had other negative hallucination on not hearing a sound that Illusion/distortion hallucinations, although he claimed that is below the auditory threshold. A per- he got a traffic ticket for going through a son who perceived a crowded intersec- 98 MEDICINE & HEALTH/RHODE ISLAND tion while driving but did not see a stop what was said. Only 10% of subjects with Disclosure of Financial Interests sign might have had a negative halluci- reported negative hallucinations had Joseph Friedman, MD, and spouse/sig- nation, or might simply have been day- them during the study, so that only 4 sub- nificant other. Consultant: Acadia Pharmacy, dreaming, or not paying attention. jects could be used. Each one of these Ovation, Transoral; Grant Research Support: To test the hypotheses that negative showed increased fMRI activity in the Cephalon, Teva, Novartis, Boehringer-Ingelheim, hallucinations exist, and that they are supplementary visual cortex of Sepracor, Glaxo; Speakers’ Bureau: Astra Zeneca, caused by over-activity of particular brain Brodmann’s area 121, suggesting an over- Teva, Novartis, Boehringer-Ingelheim, regions, we performed functional mag- activity, as hypothesized. GlaxoAcadia, Sepracor, Glaxo Smith Kline, Neu- netic resonance imaging (fMRI) scans While this result concerns only 4 rogen, and EMD Serono. on PD patients who were taking medica- subjects, and requires confirmation, it Conflicts: In addition to the potential tions and thought to have negative hal- nevertheless should be sufficiently con- conflicts posed by my ties to industry that lucinations. Subjects were scanned while vincing that skeptical readers will at least are listed, during the years 2001-2009 I was taking their medications and exposed to consider the possibility that negative hal- a paid consultant for: Eli Lilly, Bristol Myers their spouse or a spouse stand-in, who was lucinations exist. The implications of this Squibb, Janssen, Ovation, Pfizer, makers of part of a group of three, the two others finding are widespread. each of the atypicals in use or being tested. being strangers. Each read a standard- Happy April Fool’s. ized script and the patient, was asked to describe the scene visually and to recall – JOSEPH H. FRIEDMAN, MD

Oh, How the Mighty Have Fallen Stroke remains one of the major causes of disability and death unrelated disorders involving, in one way or another, the arterial in the United States. It is a terrifyingly sudden and unwelcome blood vessels leading to or within the brain. The commonest patho- visitation. It swiftly deprives its victims of control over limb logic lesion causing stroke is a functional narrowing or occlusion muscles and even consciousness. Speech is commonly impaired of a major cerebral artery thus depriving brain tissue of its needed during the acute phases of the illness. Patients with stroke of- oxygen-carrying blood supply. About 56% of patients fell within ten identify their disease as an attack from the outside rather this diagnostic category. An additional 22% had an insufficient than a festering, internal impairment. Historically, stroke has blood supply but only transiently so (called a transient ischemic frequently been considered by its victims as a punishment rather attack or TIA) with a strong likelihood of functional recovery. About than a human affliction provoked by natural causes. 14% had a massive intracranial hemorrhage not caused by any The United States Public Health Service estimates that preceding head injury. This disorder has sometimes been called about 795,000 Americans experience a new or recurrent stroke apoplexy. The remaining 8% were clinically ill-defined. each year. In 2001 the Service initiated a broad surveillance In decades past, a diagnosis of stroke carried a dismal prog- program, enlisting 195 hospitals in Massachusetts, Georgia, nosis with hospitals providing little beyond supervised bed-rest, North Carolina and Illinois to track the prevalence, demo- supportive therapy and diligent nursing care. Patients lingered graphic features, secular trends and risk factors preceding the for weeks and were prone to develop secondary pneumonia, other disease. And in the course of these studies, some 56,969 pa- internal infections and bed sores. Inpatient medicine has ad- tients with stroke, 18 years or older, were studied. vanced considerably since then and stroke patients now are rou- What findings did this surveillance program generate? tinely treated to prevent these complications. Furthermore, ad- First, the most obvious: Stroke remains a major impediment vanced anti-thrombotic therapies are employed to reverse some to the health of Americans. Second, it continues to be an affliction of the cerebral damage. And rehabilitation services, including primarily of the elderly with a median age of onset at 72 years. It is speech therapy, occupational therapy and physiotherapy are dili- slightly more common in women (53.3%) but only because more gently prescribed to speed the recovery of the patients and to women than men survive to live beyond the age of 70. hasten their resumption of a full life in the community. What prior risk factors increase the likelihood of stroke? A And the outcome of all of these medical, nursing and reha- history of hypertension (high blood pressure) is the most pre- bilitative interventions? The in-hospital stay, instead of intermi- dictive risk factor, encountered in 73% of stroke victims. Other nable months is now measured in days: an average of 6 days in this past events that increase the likelihood of future stroke include study. And instead of an acute mortality rate of over 35% in the a previous or transient stroke (31%), a history of diabetes mel- past and most of the survivors then relegated to nursing homes, litus (28%), a history of coronary artery heart disease (28%), a the survey recorded a mortality rate of 6.8%, 40.2% transferred history of cigarette smoking (18%) or a history of atrial fibrilla- to a rehabilitation center, nursing home or hospice and the re- tion (15%). The typical stroke patient in this study carried be- mainder, about 53%, returning to their homes. A substantial im- tween two and three of these risk factors; and about one-fifth provement over the outcome data from a half-century ago. of this population of close to 57,000 patients were burdened As educational programs in preventive medicine have in- with four or more of these risk factors. fluenced an increasingly large population, the prevalence of Stroke, of course, is not a single disease but many etiologically stroke is gradually diminishing. Smoking-cessation programs, 99 VOLUME 93 NO. 4 APRIL 2010