Oliver Sacks discusses ‘Hallucinations’, Chekhov and more

Earlier this fall, I visited Oliver Sacks in his Manhattan apartment to talk about his new book “Hallucinations.� Blending case studies, personal experience and clinical observation, “Hallucinations� is, like much of Sacks’ work, an investigation into neurology, psychology, the border line between mind and body: an overview that casts hallucination not as something alien, but rather as human to the core. Sacks is smart and soft-spoken; his reflections on the book, and on the art of revelation, appeared in this Sunday’s Arts & Books. Here is more of our conversation.

What was the genesis of “Hallucinations�?

Originally, I was writing a book about various visual problems, including my own, and hallucinations. Then, in 2009, it became obvious that this book would be too large so “The Mind’s Eye� was carved off. After that, I was able to concentrate here on hallucinations. Like so many of my books, this grew out of something smaller. Originally, there were going to be two or three case studies or chapters, and then it took off. I’ve often written about hallucinations of some sort or another in the past, but I wanted to bring them all together, especially because the last few years have seen brain imaging while people are hallucinating. It’s a little like “Musicophilia,� which also started out of two or three case histories.

You start the book by writing about visual issues, particularly Charles Bonnet Syndrome, in which people who have lost their sight often see people or other figures.

I encountered this most commonly among the elderly people I see with visual problems, and I was originally going to write about it in “The Man Who Mistook His Wife for a Hat,� although for various reasons, I didn’t. I have a little bit of Charles Bonnet myself, not too exotic, but I see geometrical patterns and figures that look like writing, although I usually can’t read what they say. I’ve lost sight in my right eye.

Do these figures appear in the blind spot?

All I can say is that they take place in my visual space. They’re very clear if I close my eyes. If I look at a blank area, like a wall or ceiling, it is covered with runes, like the Rosetta Stone. Occasionally I will get a word....

Throughout the book, you make the case that hallucinations are real, or substantial experiences, profound in their own right.

Hallucinations are not like imagination. They’re much more like perception, but unexpected perceptions that you haven’t ordered and don’t own, and may not control. And they may behave in their own fashion, quite oblivious of you. This is certainly the case with something like the Charles Bonnet hallucinations.

With Charles Bonnet, the activity is relatively low, confined to the visual. You may see faces, all distinctive but none of them recognizable and none of them noticing you. But at higher levels, you are very much involved and you may have a strong feeling of agency. You also often have your waking critical intelligence. A fellow physician saw God during temporal lobe seizures -- a white bearded iconic image, with whom she argued. God said, “Don’t you believe your senses?� And she said, “Not when I’m having a temporal lobe seizure.�

You touch a bit on psychosis and schizophrenia, but this is not a big part of the book.

In a way, coming from the clinical or physiological end, I’m most concerned with what goes on in the brain while one is hallucinating. Questions of meaning, they’re not my concern. There are many, many sorts of hallucinations.

You often refer to the case study as part of both your literary and your medical heritage. What is the value of narrative as a clinical tool?

Where the earlier descriptions of patients were often detailed, rich, empathetic, even novelistic, after publication of the first DSM, things changed. Instead of a description, one would be given a list of fulfilled criteria, sort of a checklist, suitable for a diagnosis and reimbursement. So much so that you look at some of these charts and you have no idea what the person was like, what their experience was. Basically, you were just given a diagnosis. When I worked in a migraine clinic in the 1960s, it was easy enough to make the diagnosis of migraine, but then the challenge was: What role does this play in your life?

For people such as Dostoevsky, there’s a kind of bliss, or even transcendence, attached.

George Eliot wrote that she would feel dangerously well before a migraine.

The stories bring their own meaning, a way of understanding the experience from the inside.

In 1986, I met Francis Crick. I met him at a dinner, and he took me by the shoulders and sat me down next to him and said, “Tell me stories.� I said, “What sort of stories?� And he said, “Stories of visual disorder and perceptual disorder.� These great theorists were parched for evidence -- whether it was experimental evidence or cases. So I hope these cases will stimulate other people as well.

How do your literary and clinical goals coincide or contradict each other?

Chekhov said, “Literature is my mistress and medicine my lawful wedded wife.� Or something like that. And some of Chekhov’s tales could only have been written by a physician. Like “Ward Six.� But the clinical and literary aspirations seem to come together to some extent in the case history, although I am uneasy with the word “literary.� I was particularly annoyed at being misquoted by the Wall Street Journal. I was asked, “Are you a writer first or a physician first?� I said, I’m a physician first and then a writer.� They put it the other way round.

I think I always respect the patients, but this coincides with the desire to write, which is uncontrollable and deep. Some of my stuff is considered kosher by my colleagues and in allowable case history format. But that certainly wasn’t the case with “Awakenings� when it came out. It was something of a literary sensation in England in 1973, but there was not a single medical review or response.

In “Hallucinations,� you touch on fatal nightmares, and memories or images that haunt us in what seems to be a malignant or dangerous way. Do you think there’s a real relationship there? Can our beliefs affect reality that directly?

In general, not. Although there are some interesting coincidences. There was an autobiographical account in the 1920s by a man who’d been obsessed by images of trains. “The Locomotive God� was the title. When he was 3 or something, he saw a locomotive with a glaring light and smoke; he thought of it as a mythical beast or a god. Two weeks after the book was published, he was killed by a train. The discoverer of iridium was obsessed throughout his life by the fact that his parents had been killed because their horse-drawn carriage overturned. He walked a great deal and avoided carriages. But one day, he took a carriage and the horse bolted or something and the carriage overturned. And he was killed. An eminent stand-up comedian lost his mother when he was 12. She committed suicide by drowning and said: “You will follow me.� When I saw him, in the course of an unrelated neurological problem, he was haunted by this command and I got a sense of helplessness. And he did commit suicide; he drowned himself. One somehow felt that fate had intervened. A psychiatrist might be able to give you many examples, but certainly I, too, have felt endangered by many things.

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