Ask Dr James: What do vivid hallucinations really mean?
Dear Dr James,
I regularly visit an elderly neighbour who's living alone but managing well despite poor eyesight from macular degeneration. She has recently started seeing the most vivid scenes on her living room wall, some ordinary – children playing, trees, buildings – others more fantastical such as a brightly coloured circus troupe. These last a few moments before fading away. She is not particularly disturbed by her 'private film shows'( as she calls them) but is hesitant about mentioning them to her doctor.
Dear Reader,
Though we have the overwhelming impression that the colour and forms of the world 'out there' are streaming through our eyes as through an open window, they are rather 'created' by the neuronal circuits of the visual cortex and associated areas of the brain. These are some of the reasons she might be experiencing hallucinations such as these.
Visual impairment
The constant barrage of nerve impulses transmitted from the retina at the back of the eye along the visual pathways is markedly diminished in those with poor eyesight. To compensate the brain fills the void with imagined or recalled images. This is the Charles Bonnet syndrome named in reference to the French philosopher who, in 1760, first described in great detail the phenomenon as experienced by his 89-year-old grandfather afflicted with cataracts.
Though aware of their illusory nature, he described seeing colourful birds and tapestries and 'young dancing girls dressed in yellow silks with rose-coloured ribbons, pearl collars and diamond pendants'. In a more recent account from a decade ago, Australian neurologist Prof Chris Plummer observed how the hallucinations tend to be stereotypical with recurring themes of trees, brightly coloured vehicles, caterpillars, distorted faces – and sequential, morphing one into another. Thus one woman reported how 'the carpet in her room would lift away from the floor, roll up in the form of a snake and slither under the door', while for another 'a draught horse pulling a cart transformed into a chariot before speeding away'.
The hallucinations occur more frequently when drowsy and in dimly lit conditions, lasting from a few seconds to several hours. Conversely they may be relieved, Prof Plummer reports, by rapid blinking of the eyes or keeping them tightly shut. The good news is that diversionary activities (such as watching the television) can abolish them.
What else could it be?
Similar hallucinations featuring people, animals and children playing may occur in those with Parkinson's. Though initially benign, they become more threatening as the illness progresses posing a particular challenge as they are exacerbated by the drugs such as levodopa required for treating the characteristic disorders of movement. They may also occur (if rarely) during a severe attack of migraine.
What are the treatment options?
There is no specific remedy so a clear explanation of their cause is essential, along with the firm reassurance they are not a sign of psychiatric illness and should gradually diminish in frequency and intensity over time. If they are particularly distressing they may warrant treatment with drugs such as gabapentin and carbamazepine though their relative efficacy has not been formally investigated.
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