Monthly Archives: December 2020

Where the voices come from

Schizophrenia & Psychotic Disorder, Treatment Approaches, , , ,

Sometimes I get this question from patients’ family, asking why the patient is hearing voices, how did it happen and what else do we know about these voices.

Here I’m referring to auditory hallucination commonly seen in people suffering from schizophrenia and psychotic disorders.

Yes they hear voices in their head, usually talking to them, quite commonly saying harsh and mean things to the sufferer. Sometimes they hear a few different voices having a conversation, and it’s not difficult to guess, the conversation is about the sufferer.

“Look! She has no friend! She looks so ugly and stupid!”

“Indeed. I wouldn’t want to befriend someone like her.”

“She should just kill herself. Nobody likes her anyway. Why is she still living?”

I mean, who with a sane mind would say such things to others? Nobody. How was these produced?

In 1993, McGuire and Murray published a research article “Increased blood flow in Broca’s area during auditory hallucinations in schizophrenia“. Let me break it down a little for you… The functions of Broca’s area has a lot to do with “speech production”. As compared to another area of the brain, the Wernicke’s area, is responsible for the comprehension of speech.

Locations of Broca's Area and Wernicke's Areas. (NIDCD, 2010) | Download Scientific Diagram
Locations of Broca’s and Wernicke’s. Picture taken from researchgate.net

So what does this mean?

When the patients are hearing voices, which do not sound like their own voices, the “speech production” area of the brain has increased blood flow, less so in the “speech comprehension” area. We can’t conclude anything from here obviously, but it becomes clearer to the researchers that those voices are produced by the brain itself, almost like their own’s thought processes (which we all do: talking to ourselves or having inner talks), but “presented” as somebody else’s voice.

So it seems likely that it’s their own thoughts. At least that’s what research has found. And I believe many clinicians would agree with me — often we see those voices are actually the patients’ core beliefs, worries, and are what they were told (by their parents, significant family members, teachers etc) when they were much younger. As a therapist, when I look at it this way, it opens up a lot more possibilities to help people who are suffering from auditory hallucination. And indeed, quite a number of techniques in mindfulness-based approach and cognitive therapy have been found useful.

被压抑的创伤事故？

Anxiety Disorder, Issues & Debates, ,

在中国做培训的时候，发现学生蛮常喜欢问关于“创伤” (trauma) 相关的问题。过去几十年，创伤是心理学里一个很“夯”的课题，许多抑郁、焦虑、人格障碍 (personality disorder) 等心理与精神疾病，都会被与创伤事故做联想，并以此角度去谘商与治疗－－这其实没有太大问题（虽然在认知行为的角度，我们更多去关注“维持因素”，而不是问题的起因）。可是随着心理知识通过网络、自助书籍等的普及化，现在连一个7、8岁的孩子，到没有受过高等教育的70、80岁的长者，都会开始说自己“受到了创伤“。换句话说，“创伤”这个词，开始被“滥用”，不适当的应用。这就有些类似好多年前开始，“忧郁”被滥用一样，后来“我有点强迫”也开始被普及化，然后现在，“创伤”也是。

当然对我来说，心理知识，尤其有科学依据的心理学知识的普及化，一点问题也没有，它增加了社会对患有心理相关问题的意识、的关注，并能让人们提前寻求帮助，以及减少偏见和歧视等，这并没有问题。问题在于，传统上，弗洛伊德派系（Freudian) 的理论，相信人们的大脑在经历重大创伤事故时，会启动防御机制(defense mechanism)，比如抑制(repression)，把不合理的信念、痛苦的记忆等，在你无意识、不自觉的情况下隐藏它们，以期完全忘记它们。

而这才是我今天想要关注的主题：这种被压抑、被忘却的创伤，存在吗？

我想不少心理学家都会异口同声说：“当然存在！” 以前的我也是。可是这里，我想提出几个“疑点”，让把它看成理所当然存在的人，稍微的再考虑一下下…

（一）以过去许多经历较为重大事故（如：战争、被性侵强奸、地震、911事件、恐怖袭击、攫夺等）的人过后出现闪回(flashback)、失眠等症状而被诊断为创伤后应激障碍(Post traumatic stress disorder, PTSD)，这些事故其实被更强烈的记住，并不断在脑海里“重播”，所以才会导致情绪激动、焦虑等症状。这似乎显示：经历创伤事故的人，是会更强烈的记得这些事故，而不是忘却它、压抑它？

（二）有些时候，这些创伤事故发生在我们懂事以前。在孩子还未懂事前（4、5岁之前），他很可能根本不以为意，并不知道这是“创伤性的”，或许带来一些不舒服、不自在的感觉，但是后来随着时间的飘逸过去了，多年后长大了，可能因为一些环境或电影情节，再次想起，这时候才了解当时那是什么，但在不懂事的情况下，这能算是“被压抑的创伤”吗？

（三）与（二）相关，婴儿遗忘症(infantile amnesia)，显然也不是“被压抑的创伤记忆”。因为在我们未懂事以前，几乎所有经历都没有被编码 (encode) 进入我们的长期记忆 (long-term memory)，那就没有所谓的无意识压抑了。虽然其实近几年有些研究似乎发现，学语言以前长期记忆的编码方式，与逐渐掌握语言后的编码方式不同，而导致我们在学会语言后，无法“复取”(retrieve)旧有编码的记忆。

（四）许多所谓的创伤事故，多年后在治疗，尤其催眠过程中被“记起”。在美国，这甚至导致家庭关系的破裂、引起诉讼，与家人对薄公堂。可是这里的问题是，记忆的可塑性很强，它不是文档，可以每次打开来看却还保持一样，我们的日常经历、听说的故事、看过的电视电影情节、做的梦、幻想的事情等，都会影响我们的记忆。记忆并不是事件本身，记忆是加入了许多我们的经验、想法、情绪、知识等的事件，可以与原本的事故相差甚远，甚至，毫不相关，完全是虚构的。许多研究已经证实了这件事：我们可以虚构出“事实”，并强烈相信它就是事实。所以，如何“证实”这些被发现的压抑创伤事故的虚实？？

您怎么看呢？

注：我无意淡化遭遇创伤事故的人的痛苦，这篇的内容主要在谈论“被压抑”后“被发掘”的创伤经验。临床上，我还是有在针对大小创伤事故做治疗的。

What do you do when you’re experiencing difficult emotions?

Issues & Debates, Treatment Approaches

When you’re feeling disappointed, scared, sad, low, bored, insecure, frustrated, agitated, annoyed, angry, upset, pain, stressful… What is the first thing that you do?

“What? I don’t even feel them.”

“I don’t know what I’m feeling. I feel like a robot. I feel numb. I can’t feel anything.”

Sometimes it appears to me that humans seem to have lost the ability to feel primary emotions, especially the “negative” or difficult ones.

Indeed, if a fly stand on your hand, you want to get rid of it ASAP by sway your hand. If your washing machine is broken, you want to get rid of it and buy a new one. If your room is dusty, you want to clean it up.

This is what we do in the external, physical world. We remove these “negative” things. And then problem is sorted. But, what about our inner, emotional and psychological world?

When you’re feeling sad, can you get rid of it by swaying your head maybe? When you’re frustrated and disappointed, can you simply chunk them to the bin? When you are feeling insecure and worried, can you just clean them up?

No you can’t. It doesn’t apply to the internal world this way. So we try to suppress it, fight it off, avoid it as much as possible. “Don’t cry, don’t be sad.” “Don’t be angry” This is what we were taught too. Indeed as a child, we probably thought that the adults can control their emotions, they can stop being sad or angry as they wish.

Growing up this way, believing things this way, how do we still feel? How do we still know our emotions? How do we still understand the message behind the emotions? All emotions give us some messages, whether it’s positive or negative.

When we are bored, sad, frustrated, upset etc., we commonly turn to our smartphone. Maybe reply a few whatsapp messages, maybe play my favourite game, maybe scroll a few posts on instagram or instastory. Yes, smartphone is such a life saver. At least we don’t feel the same intense painful emotions anymore.

And then…? We no longer feel. We are only anticipating joyous mood (which never lasts). We no longer understand what’s wrong, overlooking the message brought by our emotions. We feel numb, and wonder if that’s the way of living. Some people turn to alcohol and drugs, at least they won’t feel so numb.

If possible, try to spend the next two to three days noticing how you’re feeling whenever you unlock your smartphone (perhaps except when it’s in response to a notification alert). When you reach out to your phone, are you avoiding some numbness, frustration, disappointment, sadness, annoyance, fear, worry, etc? How about taking a pause and noticing how you’re feeling? Any sensation in your body? Any discomfort? Just take some time to notice it and acknowledge it. Then “decide” what you want to do next. It can be nothing…