Doc, I'm seeing things.

November 13, 2009 1:50 PM

How would a psychiatrist treat an adult who was having visual hallucinations, but no other symptoms of psychosis?

FYI, this is for fiction writing purposes. I've got character with no history of mental illness who has suddenly started seeing troubling things. He is otherwise entirely lucid, and would not exhibit any other symptoms, except a little understandable anxiety under the circumstances.

I'd like to know what a p-doc would realistically do in this situation. Would s/he medicate for the hallucinations? Or maybe just suggest therapy? Thanks for the help.

posted by Fenriss to health & fitness (18 comments total)

A psychiatrist told me (after watching Donnie Darko) that this situation is extremely unrealistic. Visual hallucinations are usually only seen in the cases of severe psychosis.
posted by goethean at 1:57 PM on November 13

I would think that the first line, if it hadn't been ruled out already, would be to look for a purely physical cause (drug, neurological, dietary issues). AFAIK, having just visual hallucinations would be a very unusual presentation of something like schizophrenia indeed. (I have a Masters in Counseling Psych, but IANAD.)
posted by thebrokedown at 1:58 PM on November 13

He'd refer the patient to a neurologist or toxicologist, I'd hope.
posted by orthogonality at 2:03 PM on November 13

Wouldn't visual hallucinations, in the absence of other psychiatric symptoms, be seen as indication of something more along the lines of abrain tumor? IANAD.
posted by palmcorder_yajna at 2:03 PM on November 13

I've mentioned Charles Bonnet syndrome on askme before, in which perfectly mentally healthy people with macular degeneration or other damage to the visual system experience complex visual hallucinations. Don't know enough about medical training to know whether a psychiatrist would be likely to be able to make such a diagnosis.
posted by holympus at 2:04 PM on November 13

A psychiatrist would probably refer the character to a neurologist who would order CT scans, MRIs, and EEGs. If they are strictly visual hallucinations, probably a referral to an ophthalmologist as well.
posted by infinitewindow at 2:06 PM on November 13

He also might tell the patient to get more sleep.
posted by frecklefaerie at 2:08 PM on November 13

The vast majority of psychiatrists would send him for a lot of physical/neurological tests and/or prescribe anti-psychotics.

There are specific therapies for people that help them tolerate hallucinations, but I highly doubt that would be the only treatment given.
posted by kathrineg at 2:10 PM on November 13

Oh, and they'd probably be curious about whether or not the patient is faking it.
posted by kathrineg at 2:11 PM on November 13 [1 favorite]

The vast majority of psychiatrists would send him for a lot of physical/neurological tests and/or prescribe anti-psychotics.

Let me qualify this--I don't know about the vast majority of them, but knowing what I know about how doctors treat psychotic symptoms, this seems to be likely.

I am not a shrink.
posted by kathrineg at 2:14 PM on November 13

I was going to mention Charles Bonnet syndrome as well. Oliver Sacks mentioned it in an episode of Radiolab that I can't seem to find again, but he said visual hallucinations were not unusual among people whose eyesight deteriorates. He said that nearly all of them don't mention it, though, because they tend to be older and they don't want people thinking they have dementia. He then confessed that he suffers from it as well, and Oliver Sacks is pretty far from crazy.

In the context of what you're writing, however, it's hard to say. If your character is younger and has no problems with eyesight, then Charles Bonnet syndrome is not going to be a likely explanation. Also, Charles Bonnet syndrome tends to manifest in mundane visual hallucinations, not anything particularly "troubling" except that there are hallucinations at all. In the Radiolab episode, the woman Sacks talked about saw people walking up and down stairs. If your character is seeing stuff that's a lot more loaded than that, like, I dunno, demons or premonitions or whatever, then the doctor isn't going to chalk it up to Charles Bonnet syndrome.

As a fellow writer, I think what the doctor will conclude depends upon a number of factors: the sort of thing the character is hallucinating, whether the character seems frightened or merely puzzled, whether the character seems to believe what he's seeing is real, whether the hallucinations seems to be related to anything going on around the character emotionally (in terms of therapy suggestions), whether the hallucinations seem to be related to any physical stimulus or circumstances (in terms of there being some neurological tangle of signals misinterpreting the outside world, and no actual psychosis), etc. All those things make a difference in whether the character will seem crazy to a doctor, and whether the patient seems crazy will determine whether he medicates him, thinks it's a tumor, or something else entirely.

For example, the old woman who suffered from Charles Bonnet syndrome didn't act crazy in any other way and seemed to acknowledge that her brain was clearly doing something odd. Her outlook was scientific. But if your character seems to think his hallucinations are anything other than that -- i.e. that they hold some meaning -- I think to most people examining him, that would be cause for concern.
posted by Nattie at 2:29 PM on November 13 [3 favorites]

Wow, great bunch of responses, Mefites! This has given me a lot to chew on. I'll put AskMe in the acknowledgments if I ever publish!
posted by Fenriss at 2:46 PM on November 13

What kind of hallucinations? Complex (as in people, objects, and scenes) or simple (as in lights, colors, lines, etc)? The latter can be caused by many things; migraines, seizure activity, a stroke, tumors, retinal detachment, and HPPD, to name a few. The former is much more rare, and generally doesn't happen in the absence of cognitive symptoms. Aside from Charles Bonnet syndrome, I can't think of any condition that would present like that.

I suspect that once schizophrenia was ruled out by an evaluation, a psychiatrist would refer the patient to a neurologist. The neurologist would run tests (checking balance, perception, reflexes, recall, etc) to look for more subtle forms of impairment, and would probably order an MRI. If epileptiform activity was suspected, they might run an EEG. They might also suggest bloodwork, just to check for anything unusual.

If nothing was found, the psychiatrist would throw some drugs at the patient to see if anything stuck; probably antipsychotics and/or anticonvulsants.

IANAD.
posted by dephlogisticated at 3:38 PM on November 13 [1 favorite]

I would say sleep deprivation would be a likely culprit, maybe just of REM sleep, so they might even suggest apnea or something like that. Straight up visual hallucinations are extremely rare though, even for people with profound disorders. Some might also suggest that if the hallucinations aren't maladaptive, why bother diagnosing anything?
posted by solipsophistocracy at 3:43 PM on November 13

I have an intermittent "oh, hey, that's not really there" problem related to multiple retinal procedures and general eye bullshit. My retina guy shrugged, said it was hallucinations, and didn't seem to consider it either interesting or worthy of further investigation.

I, of course, went home and stared at the ceiling all night, but after that, I got over it. They're not hurting anything, they're not interesting (colored spots or black spots), and they're obviously not tied into my psychological state.

If I had to have this, though, I kind of did want the Oliver Sacks-style "tiny men inside the alarm clock" crap, and I did register that complaint with the doc, who just snorted at me.
posted by fairytale of los angeles at 4:39 PM on November 13

Hallucinations can also be present during severe manic episodes in people with bipolar disorder. I should know. They're pretty minor though, like seeing things moving out of your peripheral vision. For me it was rats or just a flash of something I couldn't identify.
posted by Evangeline at 5:00 PM on November 13

It depends. As the brokedown said, they would probably try to exclude any physical cause.

Especially in older people, hallucinations can be triggered by infections (such as UTIs); if symptoms of infection are found a doctor might just prescribe antibiotics, and see if the hallucinations stop.

Here is a interesting list of non-psychiatric causes of hallucinations.

(IANAD)
posted by James Scott-Brown at 9:06 AM on November 14

I remember having a conversation with my father, a neurophysiologist and practicing psychologist about hallucinations. We were talking specifically about auditory hallucinations though, so YMMV. If I think of it next time I talk to him I'll ask about how applicable this is to visual hallucinations.

Anyway, he told me that hallucinations are far more prevalent than one would think. It's impossible to measure accurately because hallucinating can be very culturally stigmatizing and people just don't say anything unless it becomes a huge problem, but he estimated that most people hallucinate with some regularity. That's the rub, though. If it's not a problem, then it's not a problem. It's only a problem if they're persistent, intrusive, or most importantly, compelling.

If you're interested, I experience auditory hallucinations fairly regularly. Usually when going to sleep. It's usually music, and sometimes quite good. Whole bands. Sometimes an unintelligible voice or two, and occasionally someone shouting my name. Rarely, it's a perfectly clear voice that has given me advice or information that I wasn't conscious of before, which is pretty cool. It once told me where my last, lost guitar pick was. Only once, during a period of great emotional turmoil, was there a voice giving a command. It said "Do it!" I don't know what "it" was, but it was pretty unsettling, though still not compelling. Feel free to memail me if my experience intersects enough with what you're talking about.
posted by cmoj at 12:08 PM on November 14 [1 favorite]