Hallucinations, Haints and Hooey

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Once upon a time I saw a patient for followup, a woman I had seen for several visits in the past. She had voiced the usual oft-heard complaints about insomnia, changes in appetite, lack of energy, diminished interest in pleasurable activities, and other associated symptoms of chronic depression. Most of these had been addressed and had gotten at least partially better, to the point that her overall quality of life had improved, a clinical benchmark that I pay close attention to in all my patients. After all, if you’re not living better every day, what we’re doing is not working.

The sticking point here was that her chief complaint for this particular visit was continuing visual hallucinations. She would see people, most often a silent, ghostly woman, who would walk through the house, mostly staying in her bedroom. She never said anything (this patient never complained of any auditory hallucinations, just visual), but she would move things around on the dresser and sometimes even knock things off the dresser onto the floor when the patient came into the room. I pressed the patient for more details.

The objects were physically moving on the dresser, to different places than they started?

Yes.

They actually physically fell off the dresser onto the floor?

Yes

Hmm.

Now, there are a few things about hallucinations in psychiatric patients that usually hold true. The first is, most folks are very reticent to come right out and tell me about these symptoms, for fear that I will think they are “crazy”. Patients who are truly psychotic will often just not want to reveal it to others, and they may suffer silently for some time before the severity of their symptoms comes out. Secondly, hallucinations of various types are things that the patient experiences, but by definition others around them do not. If you are hearing music playing in the room where we are sitting and having coffee together and I do not hear it, and there is no discernible source for this music, you may be hallucinating it. Stands to reason. 

So, we discussed this for a few minutes more, and then I turned to her very quiet boyfriend, who was sitting in the opposite corner from the patient. He was sliding down into the chair, and it appeared that he was trying to become one with it. This was my second clue that something was not quite right here. I asked him some similar questions.

When she is seeing this woman who sweeps things off the dresser onto the floor, do you see her too?

No.

Ah. Do you see the objects on the dresser actually move?

Yes.

Ah.

Do you see them actually fall off onto the floor, as she describes?

Yes.

Hmm.

Now, before we go any further, some of my readers are most likely already aware that there is such a thing (or was, in the DSM) as folie a deux, a shared psychotic disorder:

(folie à deux |fôˌlē ä ˈdœ|noun ( pl. folies à deux |fôˌlēz| )delusion or mental illness shared by two people in close association.ORIGIN early 20th cent.: French, literally ‘shared madness.’ (OS X dictionary))

This was not that.

I was unsure at the get-go that the visual hallucinations that the patient described were legitimate. I was pretty much certain that the descriptions the boyfriend gave were bogus. The story just did not ring true from what we know and from my decades of experience interviewing and treating folks who are truly floridly psychotic. 

Why is all this important? Well, this lady was already taking medications for her depression, and they had seemed to help her. The level of her depressive symptoms was not nearly as bad as it had been on initial presentation. She was better, functioning better overall, as I alluded to in the very first paragraph. The problem that she and I had to come to grips with was that if she truly had psychotic symptoms that happened this often and were this obvious and that impaired her functioning, then I was going to at least consider and discuss with her the use of antipsychotics, big-gun drugs that treat these types of symptoms. As some of you know, they are useful and helpful drugs, but they are not without potential serious and significant side effects and risks. 

Use of antipsychotics can lead to weight gain, elevations in blood sugar and blood lipids, and even irreversible abnormal involuntary movements that can be quite debilitating, more-so than the symptoms they were prescribed to treat. They should  not be prescribed lightly, and with informed consent. 

The bottom line in this case? I decided, along with the patent, not to prescribe antipsychotics. I thought the risk to benefit ratio was too high to justify their use at this point. I was not convinced that these symptoms were severe enough to warrant that next step in medication treatment.

There are at least two major issues in play here, when all is said and done. 

One: it takes time and effort to sort out histories and stories and elicit details about symptoms, to better understand what we are treating. This is a necessary step to avoid shooting from the hip and simply writing a prescription for serious drugs that someone may not really need at all.

Two: with the ongoing changes in out healthcare system, it is going to be much easier to do exactly that-get minimal and superficial information about symptoms, reduce everything to the common denominator, and treat. Next patient. 

Complicating this, especially in the south where I practice, is the fascinating fact that people will report seeing their deceased relatives days, weeks or months after they die, hear them talk to them in actual conversations that they swear are real, and find that these phenomena are perfectly culturally acceptable. 

Are we dealing with hallucinations? Haints? Hooey?

Do people have hallucinations that are true psychiatric symptomatology? Do they actually communicate with those who have already passed on and is this a perfectly acceptable cultural norm in some places? Are stories like this made up for reasons of secondary gain or other reasons? 

What do you think?

 

 

10 thoughts on “Hallucinations, Haints and Hooey

  1. It’s said we use only a small portion of our “brain power” because it’s all we know how to use. Theorists suggest we might actually be able to levitate objects if only we understood how to do so, which seems a little far-fetched, but who knows? The possibility intrigues me, and helps me answer your query: I’m not surprised by anything of this nature. I guess the key issue for everyone is danger. Do hallucinations place the individual, or anyone else, at risk? Many fine poets, William Blake for one, experienced “visions.” (And the suicide rate for poets and writers is, I think, highest among all the arts) So for me, the question becomes: When is a hallucination actually a vision, and when is a vision a hallucination? Perhaps it’s “academic” (a matter of semantics) and makes no difference in your practice, though I’d love to have your reaction when time permits. For the record: I’ve never had full-blown visions or hallucinations, though I’ve had periods of intense inspiration when writing, or about to write, and for me–it’s close.

  2. During my 30s and before a major “spiritual emergency” that led to “spiritual emergence,” I would have said hooey AND bunkum. Now? No. Some people have the gift/curse of seeing in and through the “thin places.” Some things that look like psychosis to mental health professionals aren’t that at all, but it’s a near-impossible conversation to have unless the mental health professional understands (is open to) psycho-spiritual issues.

  3. I was house hunting with my mother. While looking at a new decent house, a dog kept whining and barking. I didn’t want that house. I bought the new one across the street. The first woman that lived in the whining dog house went out on her motorcycle and skidded off of a cliff. Hunters found her body later. The widower immediately rented the house to a young expecting couple. She went in the bathroom and passed out. She didn’t crumple, but went straight and rigid as log. Her stomach hit the edge of the bathtub, 7-8 months pregnant, and she lost the baby. She almost died. Her husband was arrested. The owner said his wife changed B4 the motorcycle accident. Police let the husband go. The next woman had the garage door open, and was dry cleaning clothes with a flammable cleaner. She was just outside of the garage about 20 ft. from the gas hot water heater. The heater ignited it, and she died the next day. At a neighborhood coffee klatch, my mother said that I was lucky that I didn’t buy it. I said that I couldn’t stand the whining and barking of that dog. Dr. Greg, nobody owned a dog. Everybody said -What dog? I don’t have one. My mother said that she never heard a dog. For whatever reasons that existed in the late 1960s, the mortgage company declared the house as haunted, got the insurance company to help the owner, and they bulldozed it. This was in San Diego, CA. We wondered about the dog, and why the rest of us were safe. This is the only time that I had an auditory hallucination. Do I believe that objects can move by themselves? I wouldn’t say no, but I’ve never seen anything move unless there is an earthquake or something.

  4. Having seen my share of tardive dyskinesia, it’s good to be wary of psych meds as a first resort, unless there is imminent harm suspected. As to the hallucinations question, I would want to explore lucid dreaming. Were these wake states, for example, or somnambulation? Would be good rule outs, I think.

  5. Hello Greg, this is so very fascinating.
    Could it be that, as a deeply depressed person she needs to feel an “interesting” case, and that her boyfriend, in the fear that she leaves him for lack of support from his side, concurs with her for that reason only? His body attitude is weird.
    Anyway, you took the best possible decision, as usual. :)

  6. Meredith,

    I am fascinated by this phenomenon.

    Down on the coast of South Carolina, in the Gullah culture and other groups, there is a very strong belief that these things happen, that folk can communicate with the dead and that people see things that others truly cannot.

    Who am I to say that some of these events are not true and real to those that experience them. I have never done so myself and cannot “call up” such an experience, but I am beginning to believe that maybe some of these are in fact real.

    Interesting indeed.

    Greg

  7. Rob,

    I think you’re right in that there is a lot of overlap and a lot of difference in how people define these phenomena.

    I’ve never had any myself either, but I have certainly experienced an altered state when writing something very important to me, when I felt that I simply “checked out” for a little while and the piece almost wrote itself.

    The older I get the more I believe that there are things that I can never hope to fully understand, and that if I will just be openminded about them, there will be many fascinating things for me to learn.

    Greg

  8. Aye, Doc, there’s the rub: remaining openminded while growing older. For most, it goes the other way, and thank you for helping me understand this. Ergo, the fact that I’ve recently lost a significant number of long-term friendships is not necessarily my fault. In each case, I have remained openminded about everything, while they haven’t. It could be as simple as that. What do I owe you? (I pay in scallop shells)

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