Hallucinations (4 page)

I
f some or all sight is preserved, as with Charles Lullin and Zelda, there may be not only visual hallucinations but
various disorders of visual perception: people or objects may appear too large or too small, too near or too far; there may be too little or too much color or depth; misalignment, distortion, or inversion of the image; or problems with motion perception.

If, of course, the person is completely blind, as Rosalie is, then there can only be hallucinations, but these may also show anomalies of color, depth, transparency, motion, scale, and detail. CBS hallucinations are often described as having dazzling, intense color or a fineness and richness of detail far beyond anything one sees with the eyes. There are strong tendencies to repetition and multiplication, so that one may see rows or phalanxes of people, all dressed similarly and making similar motions (some early observers referred to this as “numerosity”). And there is a strong tendency to elaboration: hallucinatory figures often seem to be wearing “exotic dress,” rich robes, and strange headgear. Bizarre incongruities often appear, so that a flower may protrude not from someone’s hat but from the middle of their face. Hallucinatory figures may be cartoonlike. Faces, in particular, may show grotesque distortions of the teeth or eyes. Some people hallucinate text or music. But by far the commonest hallucinations are the geometrical ones: squares, checkerboards, rhomboids, quadrangles, hexagons, bricks, walls, tiles, tessellations, honeycombs, mosaics. Simplest of all, and perhaps most common, are phosphenes, blobs or clouds of brightness or color, which may or may not differentiate into anything more complex. No single individual has all of these perceptual and hallucinatory phenomena, though some people may have a great range, like Zelda, while others tend to stick to a particular form of hallucination, like Marjorie, with her “musical eyes.”

In the last decade or two, Dominic ffytche and his colleagues
in London have done pioneering research on the neural basis of visual hallucinations. Based on the detailed reports of dozens of subjects, they developed a taxonomy of hallucinations, including categories like figures with hats, children or small people, landscapes, vehicles, grotesque faces, text, and cartoonlike faces. (This taxonomy is described in a 2000 paper by Santhouse et al.)

With this classification in hand, ffytche went on to do detailed brain-imaging studies in which selected patients with different categories of visual hallucinations were asked to signal the beginning and end of their hallucinations while being scanned.

There was, as ffytche et al. wrote in a 1998 paper, “a striking correspondence” between the particular hallucinatory experiences of each patient and the particular portions of the ventral visual pathway in the visual cortex which were activated. Hallucinations of faces, of color, of textures, and of objects, for example, each activated particular areas known to be involved in specific visual functions. When there were colored hallucinations, there was activation of areas in the visual cortex associated with color construction; when there were facial hallucinations of a sketchlike or cartoonlike character, there was activation in the fusiform gyrus. Visions of deformed or dismembered faces or grotesque faces with exaggerated eyes or teeth were associated with heightened activity in the superior temporal sulcus, an area specialized for the representation of eyes, teeth, and other parts of the face. Text hallucinations are associated with abnormal activation in the visual word form area, a highly specialized area in the left hemisphere.

Ffytche et al. observed, moreover, a clear distinction between normal visual imagination and actual hallucination—thus,
imagining a colored object, for example, did not activate the V4 area, while a colored hallucination did. Such findings confirm that, not only subjectively but physiologically, hallucinations are unlike imagination and much more like perceptions. Writing of hallucinations in 1760, Bonnet said, “The mind would not be able to tell apart vision from reality.” The work of ffytche and his colleagues shows that the brain does not distinguish them, either.

There had never before been direct evidence of such a correlation between the contents of a hallucination and the particular areas of cortex activated. We have long known, from observation of people with specific injuries or strokes, that different aspects of visual perception (color perception, face recognition, movement perception, etc.) depend on highly specialized areas of the brain. Thus, for example, damage to a tiny area of the visual cortex called V4 may knock out color perception but nothing else. Ffytche’s work is the first to confirm that hallucinations make use of the same visual areas and pathways as perception itself. (Ffytche has emphasized more recently, in papers on the “hodology” of hallucinations, that attributing hallucinations, or any cerebral function, to specific brain regions has its limitations, and that one must pay equal attention to the connections between these areas.)
⁸

But while there are neurologically determined categories of visual hallucination, there may be personal and cultural determinants, too. No one can have hallucinations of musical notation or numbers or letters, for example, if they have not actually seen these at some point in real life. Thus experience and memory may influence both imagery and hallucination—but with CBS, memories are not hallucinated in full or literal form. When people with CBS hallucinate people or places, they are almost never recognizable people or places, only plausible or invented ones. CBS hallucinations give one the impression that, at some lower level, in the early visual system, there is a categorical dictionary of images or part images—of generic “noses,” for example, or “headwear” or “birds,” rather than of particular noses or headwear or birds. These are, so to speak, the visual ingredients called upon and used in the recognition and representation of complex scenes—elements or building blocks which are purely visual, without context or correlation with other senses, without emotion or particular associations of place or time. (Some researchers have called them “proto-objects” or “proto-images.”) In this way, CBS images seem more raw, more obviously neurological, not personal like those of imagination or recollection.

Hallucinations of text or musical scores are intriguing in this regard, for although they initially look like real music or text, they quickly reveal themselves to be unreadable, in the sense that they have no shape, no tune, no syntax or grammar. Although Arthur S. at first thought he might be able to play
his hallucinatory musical scores, he soon realized that he was seeing “a potpourri of musical notation, without any meaning.” Similarly, text hallucinations lack meaning; they may, on closer inspection, not even be actual letters but letter-like runes.

We know (from studies by ffytche and his colleagues) that text hallucinations go with hyperactivity in the visual word form area; there are probably analogous (though more widespread) activations with hallucinations of musical notation, though these have yet to be “caught” on fMRI. In the normal process of reading text or scores, what is initially deciphered in the early visual system goes on to higher levels where it acquires syntactical structure and meaning. But in hallucinations of text or scores, caused by anarchical hyperactivity in the early visual system, letters, proto-letters or musical notation appear without the normal constraints of syntax and meaning—providing a window into both the powers and the limitations of the early visual system.

Arthur S. saw musical notation of fanciful elaboration, far more ornate than any real score. CBS hallucinations are often fanciful or fantastical. Why should Rosalie, a blind old woman in the Bronx, see figures in “Eastern dress”? This strong disposition to the exotic, for reasons we do not yet understand, is characteristic of CBS, and it would be fascinating to see whether this varies in different cultures. These strange, sometimes surreal images, of boxes or birds perched atop people’s heads or flowers coming out of their cheeks, make one wonder whether what is occurring is a sort of neurological mistake, a simultaneous activation of different brain areas, producing an involuntary, incongruous collision or conflation.

The images of CBS are more stereotyped than those of
dreams and at the same time less intelligible, less meaningful. When Lullin’s notebook, lost for a century and a half, resurfaced and was published in a psychology journal in 1902 (just two years after Freud’s
Interpretation of Dreams
), some wondered whether the hallucinations of CBS might afford, as Freud felt dreams did, “a royal road” to the unconscious. But attempts at “interpreting” CBS hallucinations in this sense bore no fruit. People with CBS had their own psychodynamics, of course, like everyone else, but it became apparent that little beyond the obvious was to be gained from analyzing their hallucinations. A religious person might hallucinate praying hands, among other things, or a musician might hallucinate musical notation, but these images scarcely yielded insights into the unconscious wishes, needs, or conflicts of the person.

Dreams are neurological as well as psychological phenomena, but very unlike CBS hallucinations. Dreamers are wholly enveloped in their dreams, and usually active participants in them, whereas people with CBS retain their normal, critical waking consciousness. CBS hallucinations, even though they are projected into external space, are marked by a lack of interaction; they are always silent and neutral—they rarely convey or evoke any emotion. They are confined to the visual, without sound, smell, or tactile sensation. They are remote, like images on a cinema screen in a theater one has chanced to walk into. The theater is in one’s own mind, and yet the hallucinations seem to have little to do with one in any deeply personal sense.

O
ne of the defining characteristics of Charles Bonnet hallucinations is the preservation of insight, the realization that a hallucination is not real. People with CBS are occasionally
deceived by a hallucination, especially if it is plausible or contextually appropriate. But such mistakes are quickly realized to be such, and insight is restored. The hallucinations of CBS almost never lead to persistent false ideas or delusions.

The ability to evaluate one’s perceptions or hallucinations, however, may be compromised if there are other underlying problems in the brain, especially those which impair the frontal lobes, since the frontal lobes are the seat of judgment and self-evaluation. This may happen transiently, for example, with a stroke or head injury; fever or delirium; various medications, toxins, or metabolic imbalances; dehydration or lack of sleep. In such cases, insight will return as soon as cerebral function returns to normal. But if there is an ongoing dementia, like Alzheimer’s or Lewy body disease, there may be less and less ability to recognize hallucinations as such—which, in turn, may lead to frightening delusions and psychoses.

Marlon S., in his late seventies, has progressive glaucoma and some mild dementia. He has been unable to read for the last twenty years, and for the last five years has been virtually blind. He is a devout Christian and still works as a lay minister in prisons, as he has done for the last thirty years. He lives alone in an apartment, but he leads a very active social life. He goes out each day, either with one of his children or with a home attendant, to family occasions or to the senior center, where there may be games, dancing, going out to restaurants, and other activities.

Although he is blind, Marlon seems to inhabit a world that is very visual and sometimes very strange. He tells me that he often “sees” his surroundings—he has lived most of his life in the Bronx, but what he sees is an ugly, desolate version of the Bronx (he describes it as “shabby, old, much older than
me”), and this may give him a feeling of disorientation. He “sees” his apartment, but he can easily get lost or confused. Sometimes, he says, the apartment gets “as big as a Greyhound bus terminal,” and at other times it contracts, becoming “as skinny as a railroad apartment.” In general, the hallucinated apartment looks dilapidated and chaotic: “My whole house is a wreck, looks like the Third World … then it looks regular.” (The only time his apartment actually
is
a mess, his daughter told me, is when Marlon, thinking that he is “blockaded” by the furniture, starts rearranging it, pushing things to and fro.)

His hallucinations started about five years ago and were at first benign. “In the beginning,” he told me, “I saw a lot of animals.” They were followed by hallucinations of children—multitudes of them, just as there would always be multitudes of animals. “All of a sudden,” Marlon remembered, “I see all these kids come in, they were walking all around; I thought they were regular kids.” The children were silent but “talked with their hands”; they seemed unconscious of him and “did their own thing”—walking around, playing. He was startled when he found that no one else saw them. It was only then that he realized that his “eyes were playing tricks” on him.

Marlon enjoys listening to talk shows, gospel, and jazz on the radio, and when he does so, he may find his sitting room crowded with hallucinatory people who are also listening. Sometimes their mouths move as if they are speaking or singing along with the radio. These visions are not unpleasant, and they seem to provide a sort of hallucinatory comfort. It is a social scene, which he enjoys.
⁹

In the last two years, Marlon has also started to see a mysterious man who always wears a brown leather coat, green pants, and a Stetson hat. Marlon has no idea who it is but feels that this man has a special message or meaning, though what the message or meaning is eludes him. He sees this figure at a distance, never close up. The man seems to float through the air rather than walk, and his figure can become enormous, “as tall as a house.” Marlon has also spotted a small, sinister trio of men, “like FBI, a long way off.… They look real, real ugly and bad.” Marlon believes in angels and devils, he tells me, and he feels that these men are evil. He has started to suspect that he is under surveillance by them.