Aphantasia

Aphantasia (pronounced ay-fan-tay-zhuh)

The inability voluntarily to recall or form mental images.

2015: The word (not the diagnosis) was coined by UK neurologist Dr Adam Zeman (b 1957), neuropsychologist Dr Michaela Dewar (b 1976) and Italian neurologist Sergio Della Sala (b 1955), first appearing the paper Lives without imagery.  The construct was a- (from the Ancient Greek ἀ- (a-), used as a privative prefix meaning “not”, “without” or “lacking” + phantasía (from the Greek φαντασία (“appearance”, “imagination”, “mental image” or “power of imagination”, from φαίνω (phaínō) ( “to show”, “to make visible” or “to bring to light”).  Literally, aphantasia can be analysed as meaning “an absence of imagination” or “an absence of mental imagery” and in modern medicine it’s defined as “the inability voluntarily to recall or form mental images”.  Even in Antiquity, there was some meaning shift in phantasía, Plato (circa 427-348 BC) using the word to refer generally to representations and appearances whereas Aristotle (384-322 BC) added a technical layer, his sense being faculty mediating between perception (aisthēsis) and thought (noēsis).  It’s the Aristotelian adaptation (the mind’s capacity to form internal representations) which flavoured the use in modern neurology.  Aphantasia is a noun and aphantasic is a noun & adjective; the noun plural is aphantasics.

Scuola di Atene (The School of Athens, circa 1511), fresco by Raphael (Raffaello Sanzio da Urbino, 1483–1520), Apostolic Palace, Vatican Museums, Vatican City, Rome.  Plato and Aristotle are the figures featured in the centre.

In popular use, the word “aphantasia” can be misunderstood because of the paths taken in English by “phantasy”, “fantasy” and “phantasm”, all derived from the Ancient Greek φαντασία (phantasía) meaning “appearance, mental image, imagination”.  In English, this root was picked up via Latin and French but the multiple forms each evolved in distinct semantic trajectories.  The fourteenth century phantasm came to mean “apparition, ghost, illusion” so was used of “something deceptive or unreal”, the connotation being “the supernatural; spectral”.  This appears to be the origin of the association of “phantas-” with unreality or hallucination rather than normal cognition.  In the fifteenth & sixteenth centuries, the spellings phantasy & fantasy were for a time interchangeable although divergence came with phantasy used in its technical senses of “mental imagery”; “faculty of imagination”; “internal representation”, this a nod to Aristotle’s phantasía.  Fantasy is the familiar modern form, used to suggest “a fictional invention; daydream; escapism; wish-fulfilment, the connotation being “imaginative constructions (in fiction); imaginative excess (in the sense of “unreality” or the “dissociative”); indulgence (as in “speculative or wishful thoughts”)”.

While the word “aphantasia” didn’t exist until 2015, in the editions of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) published between 1952 (DSM-I) and 2013 (DSM-5), there was not even any any discussion (or even mention) of a condition anything like “an inability voluntarily to recall or form mental images”.  That’s because despite being “a mental condition” induced by something happening (or not happening) in the brain, the phenomenon has never been classified as “a mental disorder”.  Instead it’s a cognitive trait or variation in the human condition and technically is a spectrum condition, the “pure” aphantasic being one end of the spectrum, the hyperaphantasic (highly vivid, lifelike mental imagery, sometimes called a “photorealistic mind's eye”) the other.  That would of course imply the comparative adjective would be “more aphantasic” and the superlative “most aphantasic” but neither are standard forms.

If That rationale for the “omission” was the DSM’s inclusion criteria including the requirement of some evidence of clinically significant distress or functional impairment attributable to a condition.  Aphantasia, in isolation, does not reliably meet this threshold in that many individuals have for decades functioned entirely “normally” without being aware they’re aphantasic  while others presumably had died of old age in similar ignorance.  That does of course raise the intriguing prospect the mental health of some patients may have been adversely affected by the syndrome only by a clinician informing them of their status, thus making them realize what they were missing.  This, the latest edition of the DSM (DSM-5-TR (2022)) does not discuss.  The DSM does discuss imagery and perceptual phenomena in the context of other conditions (PTSD (post-traumatic stress disoder), psychotic disorders, dissociative disorders etc), but these references are to abnormal experiences, not the lifelong absence of imagery.  To the DSM’s editors, aphantasis remains a recognized phenomenon, not a diagnosis.

Given that aphantasia concerns aspects of (1) cognition, (2) inner experience and (3) mental representation, it wouldn’t seem unreasonable to expect the condition now described as aphantasia would have appeared in the DSM, even if only in passing or in a footnote.  However, in the seventy years between 1952-2022, over nine editions, there is no mention, even in DSM-5-TR (2022), the first volume released since the word was in 2015 coined.  That apparently curious omission is explained by the DSM never having been a general taxonomy of mental phenomena.  Instead, it’s (an ever-shifting) codification of the classification of mental disorders, defined by (1) clinically significant distress and/or (2) functional impairment and/or (3) a predictable course, prognosis and treatment relevance.  As a general principle the mere existence of an aphantasic state meets none of these criteria.

Crooked Hillary Clinton in Orange Nina McLemore pantsuit, 2010.  If in response to the prompt "Imagine a truthful person" one sees an image of crooked Hillary Clinton (b 1947; US secretary of state 2009-2013), that obviously wrong but is not an instance of aphantasia because the image imagined need not be correct, it needs just to exist.

The early editions (DSM-I (1952) & DSM-II (1968)) heavily were slanted to the psychoanalytic, focusing on psychoses, neuroses and personality disorders with no mention of any systematic treatment of cognition as a modular function; the matter of mental imagery (even as abstract though separated from an imagined image), let alone its absence, wholly is ignored.  Intriguingly, given what was to come in the field, there was no discussion of the cognitive phenomenology beyond gross disturbances (ie delusions & hallucinations).  Even with the publication of the DSM-III (1980) & DSM-III-R (1987), advances in scanning and surgical techniques, cognitive psychology and neuroscience seem to have made little contribution to what the DSM’s editorial board decided to include and although DSM-III introduced operationalized diagnostic criteria (as a part of a more “medicalised” and descriptive psychiatry), the entries still were dominated by a focus on dysfunctions impairing performance, the argument presumably that it was possible (indeed, probably typical) for those with the condition to lead, full, happy lives; the absence of imagery ability thus not considered a diagnostically relevant variable.  Even in sections on (1) amnestic disorders (a class of memory loss in which patients have difficulty forming new memories (anterograde) or recalling past ones (retrograde), not caused by dementia or delirium but of the a consequence of brain injury, stroke, substance abuse, infections or trauma), with treatment focusing on the underlying cause and rehabilitation, (2) organic mental syndromes or (3) neuro-cognitive disturbance, there was no reference to voluntary imagery loss as a phenomenon in its own right.

Although substantial advances in cognitive neuroscience meant by the 1990s neuropsychological deficits were better recognised, both the DSM-IV (1994) and DSM-IV-TR (2000) continued to be restricted to syndromes with behavioural or functional consequences.  In a way that was understandable because the DSM still was seen by the editors as a manual for working clinicians who were most concerned with helping those afflicted by conditions with clinical salience; the DSM has never wandered far into subjects which might be matters of interesting academic research and mental imagery continued to be mentioned only indirectly, hallucinations (percepts without stimuli) and memory deficits (encoding and retrieval) both discussed only in the consequence of their affect on a patient, not as phenomenon.  The first edition for the new century was DSM-5 (2013) and what was discernible was that discussions of major and mild neuro-cognitive disorders were included, reflecting the publication’s enhanced alignment with neurology but even then, imagery ability is not assessed or scaled: not possessing the power of imagery was not listed as a symptom, specifier, or associated feature.  So there has never in the DSM been a category for benign cognitive variation and that is a product of a deliberate editorial stance rather than an omission, many known phenomenon not psychiatrised unless in some way “troublesome”.

The term “aphantasia” was coined to describe individuals who lack voluntary visual mental imagery, often discovered incidentally and not necessarily associated with brain injury or psychological distress.  In 2015 the word was novel but the condition had been documented for more than a century, Sir Francis Galton (1822–1911) in a paper published in 1880 describing what would come to be called aphantasia.  That work was a statistical study on mental imagery which doubtless was academically solid but Sir Francis’s reputation later suffered because he was one of the leading lights in what was in Victorian times (1837-1901) the respectable discipline of eugenics.  Eugenics rightly became discredited so Sir Francis was to some extent retrospectively “cancelled” (something like the Stalinist concept of “un-personing”) and these days his seminal contribution to the study of behavioural genetics is acknowledged only grudgingly.

Galton in 1880 noted a wide variation in “visual imagination” (ie it was understood as a “spectrum condition”) and in the same era, in psychology publications the preferred term seems to have been “imageless thought”.  In neurology (and trauma medicine generally) there were many reports of patients losing the power of imagery after a brain injury but no agreed name was ever applied because the interest was more in the injury.  The unawareness that some people simply lacked the facility presumably must have been held among the general population because as Galton wrote: “To my astonishment, I found that the great majority of the men of science to whom I first applied, protested that mental imagery was unknown to them, and they looked on me as fanciful and fantastic in supposing that the words “mental imagery” really expressed what I believed everybody supposed them to mean. They had no more notion of its true nature than a colour-blind man who has not discerned his defect has of the nature of colour.”

His paper must have stimulated interest because one psychologist reported some subjects possessing what he called a “typographic visual type” imagination in which ideas (which most would visualize as an image of some sort) would manifest as “printed text” which was intriguing because in the same way a computer in some aspects doesn’t distinguish between an image file (jpeg, TIFF, webp, avif etc) which is a picture of (1) someone and (2) their name in printed form, that would seem to imply at least some who are somewhere on the aphantasia spectrum retain the ability to visualize printed text, just not the object referenced.  Professor Zeman says he first became aware of the condition in 2005 when a patient reported having lost the ability to visualize following minor surgery and after the case was in 2010 documented in the medical literature in the usual way, it provoked a number of responses in which multiple people informed Zeman they had never in their lifetime been able to visualize objects.  This was the origin of Zeman and his collaborators coining “congenital aphantasia”, describing individuals who never enjoyed the ability to generate voluntary mental images.  Because it was something which came to general attention in the age of social media, great interest was triggered in the phenomenon and a number of “on-line tests” were posted, the best-known of which was the request for readers to “imagine a red apple” and rate their “mind's eye” depiction of it on a scale from 1 (photorealistic visualisation) through to 5 (no visualisation at all).  For many, this was variously (1) one’s first realization they were aphantasic or (2) an appreciation one’s own ability or inability to visualise objects was not universal.

How visualization can manifest: Lindsay Lohan and her lawyer in court, Los Angeles, December. 2011.  If an aphantasic person doesn't know about aphantasia and doesn't know other people can imagine images, their lives are probably little different from them; it's just their minds have adapted to handle concepts in another way.

Top right: What’s thought “normal” visualization (thought to be possessed by most of the population) refers to the ability to imagine something like a photograph of what’s being imagined.  This too is a spectrum condition in that some will be able to imagine an accurate “picture”, something like a HD (high definition photograph” while others will “see” something less detailed, sketchy or even wholly inaccurate.  However, even if when asked to visualize “an apple” one instead “sees a banana”, that is not an indication of aphantasia, a condition which describes only an absence of an image.  Getting it that wrong is an indication of something amiss but it’s not aphantasia.

Bottom left: “Seeing” text in response to being prompted to visualize something was the result Galton in 1880 reported as such a surprise.  It means the brain understands the concept of what is being described; it just can’t be imagined as an image.  This is one manifestation of aphantasia but it’s not related to the “everything is text” school of post-modernism.  Jacques Derrida’s (1930-2004) fragment “Il n'y a pas de hors-texte” (literally “there is no outside-text”) is one of the frequently misunderstood phrases from the murky field of deconstruction bit it has nothing to do with aphantasia (although dedicated post-modernists probably could prove a relationship).

Bottom right: The absence of any image (understood as a “blankness” which does not necessarily imply “whiteness” or “blackness” although this is the simple way to illustrate the concept), whether text or to some degree photorealistic is classic aphantasia.  The absence does not mean the subject doesn’t understand the relevant object of concept; it means only that their mental processing does not involve imagery and for as long as humans have existed, many must have functioned in this way, their brains adapted to the imaginative range available to them.  What this must have meant was many became aware of what they were missing only when the publicity about the condition appeared on the internet, am interesting example of “diagnostic determinism”.

WebMD's classic Aphantasia test.

The eyes are an out-growth of the brain and WebMD explains aphantasia is caused by the brain’s visual cortex (the part of the brain that processes visual information from the eyes) “working differently than expected”, noting the often quoted estimate of it affecting 2-4% of the population may be understated because many may be unaware they are “afflicted”.  It’s a condition worthy of more study because aphantasics handle the characteristic by processing information differently from those who rely on visual images.  There may be a genetic element in aphantasia and there’s interest too among those researching “Long Covid” because the symptom of “brain fog” can manifest much as does aphantasia.

Aphantasia may have something to do with consciousness because aphantasics can have dreams (including nightmares) which can to varying degrees be visually rich.  There’s no obvious explanation for this but while aphantasia is the inability voluntarily to generate visual mental imagery while awake, dreaming is an involuntary perceptual experience generated during sleep; while both are mediated by neural mechanisms, these clearly are not identical but presumably must overlap.  The conclusions from research at this stage remains tentative the current neuro-cognitive interpretation seems to suggest voluntary (conscious) imagery relies on top-down activation of the visual association cortex while dream (unconscious) dream imagery relies more on bottom-up and internally driven activation during REM (rapid eye movement) sleep.  What that would seem to imply is that in aphantasia, the former pathway is impaired (or at least inaccessible), while the latter may remain intact (or accessible).

The University of Queensland’s illustration of the phantasia spectrum.

The opposite syndrome is hyperphantasia (having extremely vivid, detailed, and lifelike mental imagery) which can be a wonderful asset but can also be a curse, rather as hyperthymesia (known also as HSAM (Highly Superior Autobiographical Memory) and colloquially as “total recall”) can be disturbing.  Although it seems not to exist in the sense of “remembering everything, second-by-second”, there are certainly those who have an extraordinary recall of “events” in their life and this can have adverse consequences for mental health because one of the mind’s “defensive mechanisms” is forgetting or at least suppressing memories which are unwanted.  Like aphantasia & hyperphantasia, hyperthymesia is not listed by the DSM as a mental disorder; it is considered a rare cognitive trait or neurological phenomenon although like the imaging conditions it can have adverse consequences and these include disturbing “flashbacks”, increased rumination and increased rates of anxiety or obsessive tendencies.