TRANSITORY HALUCINATORY DISPERCEPTIONS AT PUBERTY

ABSTRACT: 

The paper is a record of the clinical features of three female childs at puberty age with a fenomenology of halucinatory visual and auditive dispeceptions without cognitive impairment, exempt from other psychotic simptoms and unknown longitudinal evolution. The comments of the three cases include the discussion of the phantasmatic psychodynamic conceptualized by the psychoanalysis.

Extrapolation of hallucinatory type disorders of perception from adult to child is not without contro-versy. Phenomenological differences are so notable that most of the time only intuition supports the be-lief. The works that provide data about hallucinations in children are not too many. Before references to hallucinations, hallucinoses, and pseudo hallucinations, the Treaty of Psychopathology of the Child and Adolescent Development coordinated by Prof. Tiberiu Mircea, M.D., in its section on Perception processes and their disorders, insists on illusion phenomenon in children. To these one must cut the difference from illusion, which has an externai trigger, from imagination and phantasm which are interior psychodynamic manifestations generated by intra-psychic pulsing vectors. In other words, the triangle illusion – phantasm – hallucination has to be dis-mantled and each of its elements must be analyzed thoroughly.

In Daniel Marcelli’s Treaty of Child Psychopathology, the term hallucination is not mentioned ex-cept in connection with temporary epilepsy, a situation which we came across in one of the three cases described below.

C. C., 13 years old, comes in consultation for anxiety attacks, terrifying dreams, visual hallucinations.

As personal history: we signalled a prolonged 60-hour labour, with cranial presentation;
Weight at birth = 2400 g.
Psychomotor development = normal.
Sphincter control installed at two years of age. Sleep in the first year of life was hectic.

Social survey reveals an organized family envi-ronment.
As anatomy – pathological history we noted: re-peated adeno-amigdalitis, common infectious-conta-gious diseases of childhood but the whooping cough contracted at 7 years had a serious form.
Heredo-collateral history: not important.
History of the disorder. After the death of an aunt who used to live with the family and to whom the daughter was much attached, the girl started to dream her very often. Initially, these dreams did not scare her, but with approximately a month before coming to consultation, the dreams started to be terrifying (“the aunt pulls her and asks the girl to come with her”). Concomitantly, an anxiety in connection with school appeared (fear for the end of the semester as-sessments). After a dream where the aunt told her “I will come to take you with me when you are 14”, the girl became pale, asthenic, without appetite and started to accuse suffocations and muscular quivers. Some weeks before, the girl started to stare, being in a scared mood because she had seen her deceased aunt walking in through the door. Since then, she had visual hallucinations; she used to see her mother with her aunt’s head, or the aunt with her mother’s head. After some days, the girl had a suffocation crisis and quivers. Two days before coming to consultation, in the evening, during the last class at school, the girl got a strong cephalea, then a sensation of suffocation, precordial pains followed by a convulsion – anxious episode when visual hallucinations were present and she did not recognize her parents.

Somatic examination: Pale teguments.
Neurological examination: normal.
Psychic examination: The psychic contact is easily established orientated, temporally/spatially and to her own person.

Mood: Lively, the patient answers questions willingly, slight tachilalia.The girl is affectionate with her entourage. She complains of cephalea and fears (she is afraid to stay at home alone, but cannot be precise about the object of her fears). This anxiety had manifested itself since childhood when she dreaded staying alone, she steered clear of thieves and of domestic animals.

She used to go to her grandparents where she would hear that “The Devii turns into a cat.” and that “If a black cat walks under a coffin, the dead corp se be-comes a ghost.”

When she is made attentive, she realizes that what she sees does not represent reality. Three months before, she thought she had seen her aunt’s head through the half-open door. It seemed to be very far away, although the door was quite near. The following month, her fear of loneliness deepened because of some difficulties at school and of some dreams where her deceased aunt told her, while touching her shoulders, that she would come to take her when she turned 14. The visual hallucination replicated a month before coming to consultation: the deceased aunt appeared seated on a chair in front of the patient. In spiţe of the fact that the girl’s mother is depressive and anxious, there are not other identifiable family traumas. Atten-tion is stable but concentration is impaired.

Fixation memory: the patient remembers one word in four after repetition, and replaces the others from imagination. The raţional sphere: correct definitions and similes, she uses long, prolix sentences, de-scribing at length every term of the simile and only in the end does she render the essential. She uses in-adequate terms (e.g. the cart is “an old style”, a body drawn by another live body, while the motorcar is “a body that has only an engine”). Sometimes she needs help to discover the essential characteristics and to solve the absurd.

Psychological examination: normal intellect, in-sufficiently disciplined thinking for the age group. Jung Test reveals relevant associations like aunt = death, fear = disappeared, night = black, and a few more associations with the adjective… “good”.

Anxiety questionnaire: She is focused on fear, ex-pressed consciously.

Electroencephalogram: Generally normal aspect, but at the beginning of the spontaneous path there are some hypervolted Delta waves, isolated on the right TP, left OP and both OT derivations.

TM, 11 years old, comes for investigation following apparently unmotivated paroxysm of laughter for several hours followed by a period of impulsive violent language, auditory and visual hallucinations, depressive ideas, and headaches. In the days following a crisis she manifests mutism accompanied by crying. As history, difficult birth with asphyxia is found. Psychomotor development is normal chronologically, sphincter control was installed early (one year). During the first year, sleep was restless. The social survey indicates the fact that the girl used to be beaten and threatened because she was nervous. At school, the teacher had the same behaviour. Family conflict situation. Father “nervous and evil” a hit on the mother. School difficulties arose in the second grade and ag-gravated in the fifth grade. History: toxic dyspepsia at three months of age, measles at 3.4 years with high fever, head injury every at 4 years, with loss of con-sciousness. Family history indicates a brother suffering from the sobbing spasm.

History: Between 1 and 3 years of age the girl had affective crises. Ever since a little child she used to be irritable and emotionally labile. Academically, she be-gan to learn less, so that parents beat her. Three weeks before, the girl tried to suffocate a younger brother and hit a neighbour who had stopped her. After one night when her brother had scared her hiding in the dark-ness, she began to display hyperpnoea and tachypnea, accusing precordial pains and headache. At times, she uses to clutch at her mother’s hand, with con-fused looks and does not answer the questions. After some school conflicts, she had a crisis of unmotivated laughter that lasted three hours followed by aggres-sive manifestations. Auditory hallucinations (ringer) and visual ones (“something grey with a scythe”) were followed by agitation, self-aggressiveness, mutism and crying crises. She used to hide in a bed box asking that it should be sealed with nails. Neurologica! examination: No changes have been signalled.

Psychic examination: The psychic contact is easily established, the girl answering the questions compli-antly, with a slight logorrhea; by the end of the psychi-cal examination a slight motor instability is manifest-ed together with a suspicious look. Temporal-spatial orientation is normal. The girl has school phobia, especially fears the lowest scores. She describes “appari-tions” such as a bald man in yellow, with black buttons and a long coat. She says: “when I see the apparitions I do not know whether they are dream or reality, I think they are real, I am very scared. Other examination data are limited intellectual development, labile attention, and deficient fixing memory. Psychological examination: It points out the difficulties of adapting to school effort and the fact that thinking operates at different levels (disharmony).

EEG: normal.

• AR, 12 years old. Reasons for consultation: She would hear voices for periods up to several minutes.

Personal and hetero-collateral history: insig-nificant. Psychomotor development appropriate to chronological age. Very good school results. The patient always wants to be a prized student.

History: some time before, during the prepara-tion of home assignment, the girl started to have auditory hallucinations (she heard a female voice that said to her: Yes, yes, yes). Auditory perception disorders repeated in the coming days, being accompanied by anxiety and unmotivated crying. Neurologi-cal examination: discrete lack of coordination in the finger-to-nose test, with predominance of the right side; photo-motor reflex more slowly in the left side. Psychical examination: the girl is oriented to seif and temporal-spatially. She reported that while drawing a map at history, she suddenly heard a female voice in “the brain” that approved her and prevented her to continue working.The duration of the episode was of 1-2 minutes. During the crisis she was scared. From early childhood, the girl reported that her affection for grandmother was important for her. The first memory was the recollection of the day when her father gave her a large doll.

School efficiency: good from the very beginning.

Relationships with colleagues: active. Changing of her schoolmistress and her replacement was an emoţional trauma but she goes to visit her. Her preferred activities are reading, traditional folk music, adventure movies, handcraft. Affectively related especially to the father, her mother used to beat her while she was a little girl when she broke something. She had normal relations with her elder brothers and with colleagues was friendly. She longs to keep her place at the top of class, and to be the school leader. She does not dream, has a phobia of mice.

Fixing memory: She remembers, with hesitation, four digits while the evoked memory is very good.

Correct definitions: accurate similes, promptly identifies the absurd.

EEG provides a track indicating irritation.

DISCUSSION

The cases we presented bring evidence that, at first sight, hallucinations may have, as in adults, a disper-ceptive mechanism. But a close look at the child identifies possible invasion of the field of consciousness by the phantasm, a psychic phenomenon that distances itself from the disturbances of perception with different psychodynamic mechanisms revealed by psychoanalysis. Indeed, this calls into use the French word: fantasme, slightly different from that derived from the German Phantasie, which contains both the capacity to imagine, and the world of perceptions. The latter two terms are a key attribute assigned to the mentality of the development age. The terms of phantasm and phantasmatic clearly reflect the antithesis between imagination and the perceptive reality. Psychoanalytically thinking, phantasm is a mental phenomenon that can not stand the test work by which the Ego operates on the reality. The latter must be understood in two ways: as a perceptual reality and as mental reality discovered by means of psychoanalysis in pathogenic childhood states. Neither the “psychic reality” is synonymous with the inner world, that is, with the psychological field. In psychoanalysis sense, it means a strong, heterogeneous core which resists in this field, the only truly real in relation to most psychic phenomena. Freud said that, on the ground of unconscious desires, psychic reality is a particular form of existence not to be confused with material reality. He tried to explain the stability, strength and the quite organized character of the phantasmatic life by highlighting phantasmatic scenarios such as “family novei” and finally hereditary eruptions of original phantasms’.

There are several levels of depth of the waters in which the phantasms “swim”. First is the surface level, half-conscious or subliminal, achieved by daydream-ing. The second, which is deeper and unconscious, is the dream level. Finally, the third is abysmal, extract-ing from the depths elements of the original phantasm. This last form of phantasm appears in our cases, and in these situations, they may be wrongly labelled as being similar to the hallucinations of the adult. Another remark is that if the daydreaming phantasms may function so as to meet the imaginary wishes of the child, (some other times representing scenarios of a game that simulates different versions of reality) and dream phantasms represent an expression of nonver-bal symbols of the unconscious, abyssal or originating phantasms couple with primordial fears achieving that darkness of consciousness which is close to psychoses.

The combination between the pressure of ID or of the SE coupled with anxiety distorts the Ego re-moving its ability to test the reality and favouring the states of consciousness narrowing.

Laplanche (J) and Pontalis (JB) stated their dis-belief in the validity of Freud’s original conception, on the relationship between phantasm and deşire. This is because:

• we witness scenarios that are organized, likely to be dramatized most often in a visual form;
• the subject is always present, even in the “original scene”, where it does not figure as observer but as participant;
• there is more to it than an object covered by the subject; there is a sequence of which the subject itself is a part and exchanges of roles and actions may occur;
• the phantasms are also the place of defence op-erations, sometimes of the most primitive kind, such as turning against oneself, turning into the contrary, denial, and in particular projection.

One can only speculate about the influence of the endocrine puberty “storm” on the phantasmatic “vor-tex”. It is but natural to expect that the wave gen-erated by the glandular earthquake would sweep all the settlements erected by childhood games, leaving an empty space for the phantasmatic effort to raise other structures with a deeper foundation. The ex-tent to which these rooms will be habitable spaces for adolescents will depend on the “intelligence” of the phantasmatic scenarios put into play in composing inner reality scenarios shaped by meta-psychologi-cal vectors. The road to psychopathology is only one of the less common ways through which fantasising adolescents may move to adulthood.

The clinical cases, which we referred to, reinforce the need for caution when we tend to extrapolate adult psychopathology in children.

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