Hallucinations

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.

One 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.)