Psychosis, Mens Rea, and Criminal Conviction: Part Three of a Five-Part Series

In my last post, I detailed my own experience of psychosis.  I described my terror-driven reaction to hallucinations, as well as the unfortunate reality that police officers were on the receiving end of that reaction.  It was definitely my lowest point in life, but thankfully the story didn’t end there (more on that in another post).  In this post, I want us consider how recent neuroimaging studies can help us better understand the unintentional nature of the hallucinatory symptoms of schizophrenia (or other disorders involving psychosis, such as dementia, bipolar disorder, etc.).

Cognitive Networks and Connections

Have you ever intended to change the wiring of your brain so that you actually see your own memories while awake?  The answer is hopefully ‘no,’ because you probably didn’t know that could even happen; but an unintentional, mis-wiring of the brain is exactly what cognitive neuroscientists are implicating as the cause of hallucinations in schizophrenia.  Functional MRI (fMRI) studies help us see which parts of the brain are active and working properly with each other under various situations, and cognitive neuroscientists are now using fMRI studies to better see the neurological conditions from which persons living with schizophrenia suffer.

In a healthy brain, networks of various structures exist in a healthy and interconnected manner.  A cognitive network is a group of brain structures that operate harmoniously to perform different functions, such as relaxing or thinking.  Among other networks, we all have a central executive network, which is turned on when we think; a default mode network, which is turned on when we relax (or simply do nothing); and a salience network, which allows us to detect relevant (or irrelevant) stimuli in both the external and internal environments (i.e., stuff from the outside world and stuff inside your body).  The salience network acts as a switch board that helps us either turn our central executive network on and our default mode network off, or vice versa.

To illustrate this concept, imagine sitting at home on your couch after dinner.  You see the sun going down, and you glance down at your watch, noticing that it’s 7:00.  You remember that you have a project due tomorrow, so you get up and go to your desk and begin working.  Your salience network picked up the external stimulus of the sunset and the time, as well as the internal stimulus of your memory of tomorrow’s due date.  Thus, your brain switched from being in its relaxation mode (the default mode network) to its thinking mode (the central executive network).  This all happened successfully because the various networks in your brain were both working properly and connected properly.

Like Living in a Dream

Unfortunately, we are learning that in persons living with schizophrenia, these networks may not be connected properly.  One recent study by Lefebvre et al. (2016) used fMRI to examine the brains of 25 persons living with schizophrenia and who experienced regular visual and auditory hallucinations.  The researchers found that just before a hallucination occurred, the left hippocampus (where memories are stored) fired to the wrong structures in the salience network; and memories were being interpreted as either (external) visual or auditory stimuli.  This could imply that, at least sometimes, persons living with schizophrenia are incidentally ‘seeing’ or ‘hearing’ distorted versions of their own memories – much like living in a dream.

Another fMRI study on a man living with Parkinson’s disease, and who experienced frequent visual hallucinations due to his treatment regimen, examined which structures in the brain activated more than others during hallucinations.  The study found that during a hallucination, structures of the salience network (the bilateral insula and the bilateral cingulate gyrus) increased in activation, while structures of the visual system decreased in activation (Goetz et al., 2014).  His brain temporarily stopped picking up visual stimuli from the external environment, and it errantly picked up visual stimuli from his internal environment.  Again, this is very similar to what happens while dreaming.

All of that scientific hoopla is to say that people suffering from schizophrenia are just that – suffering.  Healthy functioning of the brain doesn’t merely depend on healthy functioning of its distinct parts; it also depends on those parts being connected properly and sending messages to the right structures.  Research is indicating that in persons suffering from schizophrenia, those structures are not connected properly.  We must respond with empathy and compassion, rather than judgment and condemnation.

How Will We Respond?

A few days ago, I was speaking with a nurse who used to work in a pediatric unit.  Having been curious about child-onset schizophrenia, I asked her, ‘How often did you see children present with hallucinations?’  Based off the statistical prevalence of child-onset schizophrenia (which was low eight years ago; David et al., 2011), I expected her to say rarely.  Instead, ‘Almost every day,’ was her answer.  Almost every day, she had a child come to the hospital because of hallucinations.

Our current beliefs, actions, and policies are creating the world those children will grow up in.  We will reap what we are currently sowing; but ten years from now, those children will reap what we’ve sown as well.  If we currently believe those children are just ‘crazy,’ ‘morally deficient,’ or ‘lunatics,’ they will grow up in a social context that sees them and treats them as such; but if we recognize that they are suffering from conditions we just don’t fully understand yet, we can respond with empathy, compassion, and love.  Just personalize the situation and ask yourself this simple question: Would you want your 7-year-old daughter to fear going to school because she was punished for reacting in terror against her own brain run amok?

References

David, C. N., Greensetin, D., Clasen, L., Gochman, P., Miller, R., Tossell, J. W., … Rapaport, J. L. (2011). Child onset schizophrenia: High rate of visual hallucinations. Journal of the American Academy of Child & Adolescent Psychiatry, 50(7), 681-686.

Goetz, C. G., Vaughan, C. L., Goldman, J. G., & Stebbins, G. T. (2014). I finally see what you see: Parkinson’s disease visual hallucinations captured with functional neuroimaging. Movement Disorders, 29(1), 115-117.

Lefebvre, S., Demeulemeester, M., Leroy, A., Delmaire, C., Lopes, R., Pins, D., … Jardri, R. (2016). Network dynamics during the different stages of hallucinations in schizophrenia. Human Brain Mapping, 37, 2571-2586.

Written by: Jordan Parks, NAMI NC Intern