Hallucinations

There is clearly a wide array, a whole spectrum, of visual disturbances which can occur when vision is lost or compromised, and originally the term “Charles Bonnet syndrome” was reserved for those whose hallucinations were related to eye disease or other ocular problems. But an essentially similar array of disturbances can also occur when the damage lies not in the eye itself but higher up in the visual system, especially the cortical areas involved in visual perception — the occipital lobes and their projections into the temporal and parietal lobes of the brain — as seems to be the case with Zelda.

Zelda was a historian who came to see me in 2008. She told me how her world of strange visual phenomena had started at a theater six years earlier, when the beige curtain in front of the stage suddenly seemed to be covered in red roses — the roses were three-dimensional, thrusting out of the curtain. When she closed her eyes, she still saw the roses. This hallucination lasted for a few minutes and then vanished. She was perplexed and frightened by this, and she went to consult her ophthalmologist, but he found no impairment of vision and no pathological changes in either eye. She saw her internist and cardiologist, but they could not provide any plausible explanation for this episode — or the countless episodes that followed. Finally she had a PET scan of her brain, which showed reduced blood flow in her occipital and parietal lobes, presumably the cause, or at least a possible cause, of her hallucinations.

Zelda has both simple and complex visual hallucinations. The simple ones may appear when she is reading or writing or watching television. One of her physicians asked her to keep a journal of her visions over a three-week period, and in it, she recorded, “As I write this page, it is becoming more and more covered by a pale green and pink lattice.… The garage walls, covered in white cinderblock, continually mutate … coming to resemble bricks, or clapboard, or being covered with damask, or flowers of different colors.… On the upper part of the walls in the hallway, shapes of animals. They were formed by blue dots.”

More complex hallucinations — battlements, bridges, viaducts, apartment houses — are especially common when she is being driven in a car (she gave up driving herself after her initial attack, six years ago). Once when she and her husband were driving along a snowy road, she was startled to see brilliant green bushes, their leaves glittering with icicles, to either side of the road. Another day, she saw a rather shocking sight:

As we drove away from the beauty parlor, I saw what looked like a teenage boy on the front hood of our car, leaning on his arms with his feet up in the air. He stayed there for about five minutes. Even when we turned he stayed on the hood of the car. As we pulled into the restaurant parking lot, he ascended into the air, up against the building, and stayed there until I got out of the car.

At another point, she “saw” one of her great-granddaughters, who rose up, moved to the ceiling, and disappeared. She saw three “witchlike” figures, motionless and hideous, with huge hooked noses, protruding chins, and glaring eyes — these also vanished after a few seconds. Zelda said she had no idea that she had so many hallucinations until she starting keeping a journal; many of them, she thought, would otherwise have been forgotten.

She also spoke of many strange visual experiences which were not quite hallucinations in the sense of being totally invented or generated but seemed to be persistences, repetitions, distortions, or elaborations of visual perceptions. (Charles Lullin had a number of such perceptual disorders, and they are not uncommon in people with CBS.) Some of these were relatively simple; thus, when she looked at me on one occasion, my beard seemed to spread until it covered my entire face and head, and then resumed its proper appearance. Occasionally, looking in a mirror, she might see her own hair rising a foot above her head and have to check with her hand to make sure it was in its usual place.

Sometimes her perceptual changes were more disturbing, as when she encountered her mail carrier in the lobby of her apartment building: “As I looked at her, her nose grew until it was a grotesque figure on her face. After a few minutes, as we stood talking, her face came back to normal.”