Hallucinations, Self Monitoring-and an Historical Injustice

I am writing to commend Flavie Waters, PhD, for her recent article on auditory hallucinations in psychiatric illness.¹ She covers the topic well. Her article is timely and I hope it will contribute to a badly needed reorientation of our field toward the positive symptoms of schizophrenia. However, I am compelled to point out an error of citation that is not the author’s fault.

Dr Waters attributes the theory that hallucinations are due to a failure of self-monitoring to Christopher Frith. In fact, the notion that hallucinations in schizophrenia result from a failure in the brain’s self-monitoring (feed forward or corollary discharge) systems was first put forward by me in 1978 in the Schizophrenia Bulletin.² Frith subsequently promoted this idea as his own. In his 1992 volume on “The Cognitive Neuropsychology of Schizophrenia,”³ he outlines as original the argument that schizophrenics suffer from a defect in feed-forward systems more or less exactly as I had 10 years earlier. He states: “I will now introduce a concept that is very central to my own account of positive symptoms: self monitoring.” (p73). He then goes on to restate the arguments I had put forward 10 years earlier, citing many of the same references I used, including Helmholtz, Sperry, and von Holtz and Mittelstead. Frith was fully aware of my paper. Toward the end of his self-monitoring section he states, in his sole reference to my work: “Feinberg (1978) has suggested that monitoring mechanisms like corollary discharge apply not only to overt movement of the limbs and eyes but also to covert actions such as thinking.” (p81). Frith does not point out that, in this paper, I applied these ideas to the first-rank symptoms of psychosis, including auditory hallucinations, ideas of mind control and autochthanous delusions.

In the ensuing years, Frith has regularly promoted my basic idea of a failure of self-monitoring as his own, occasionally citing my paper but never its contents. I published an extensive review of my ideas in the British Journal of Psychiatry ⁴ hoping it would lead Frith to correct his citations. Alas, it did not. I urge our field to read my papers and Frith’s and to render scholarly judgment.

The point is not solely one of scientific priority although this is important. My model points to a vital question on the neurophysiology in mind: how do we know that our thoughts, most of which arise spontaneously (“unwilled”), are our own? Many spontaneous thoughts are bizarre and even hateful. The patient with obsessive-compulsive disorder is plagued with tormenting thoughts. Yet we, and our obsessive patients, recognize that these bizarre and tormenting thoughts are our own.⁴ This demonstrates the operation of systems that distinguish self-generated neural activity that produces conscious experience from that which arises from external stimulation. These are the corollary discharge or feed forward systems that have long been known in sensorimotor control. I postulated that similar systems operate in the motor mechanisms of thought. It is these systems that are defective in schizophrenia (and, often, in other psychoses). Hughlings Jackson emphasized that the process of thinking is simply our most complex motor act .⁵ I hypothesized that successful sensorimotor control mechanisms are conserved through evolution and operate in this complex act. When they fail, perhaps because of errors in the massive brain reorganization of adolescence,⁶ the first rank symptoms of schizophrenia emerge.

References:

References:

1. Waters F. Auditory hallucinations in psychiatric illness. Psychiatric Times 2010;27:54-58.

2. Feinberg I. Efference copy and corollary discharge: implications for thinking and its disorders. Schizophrenia Bulletin 1978;4:636-640.

3. Frith CD. The Cognitive Neuropsychology of Schizophrenia. Hove, UK: Lawrence Erlbaum Associates; 1992.

4. Feinberg I, Guazzelli M. Schizophrenia -- a disorder of the corollary discharge systems that integrate the motor systems of thought with the sensory systems of consciousness. Br J Psychiatry 1999;174:196-204.

5. Jackson JH. Selected writings of John Hughlings Jackson. New York: Basic Books; 1958.

6. Feinberg I. Schizophrenia: caused by a fault in programmed synaptic elimination during adolescence? J Psychiatric Res. 1982/1983;17:319-334.