The Last Witness to Creation: A Case of Charles Bonnet Syndrome
Publication: The Journal of Neuropsychiatry and Clinical Neurosciences
January 12, 1999
A patient hands me this note:
I am the last witness to creation. At least, that’s how I’ve felt since I lost my sight. I can create marvelous images in my mind, invisible to the eyes of others. Sometimes the images come from a place so remote from my will that they’re no longer mine. And I, once a scientist and a rationalist, have learned to be fearful of my own self.
Alejandro is a biologist. Three years ago, he began to vomit and suffer from headaches. His wife took him to a hospital, and a cerebral tumor was found. He underwent surgery in Mexico City. The scientific name for his illness is both precise and sinister: craniopharyngioma. The patient’s wife cares for him tenderly, but he has not worked since his diagnosis. Although surgery saved his life, the tumor destroyed his optic nerves, and it will grow again. There is no way of predicting exactly when it will be necessary to intervene again. Something unexpected, however, happens every day.
“I see boats and aerial battles. But I prefer seeing rare fish, seahorses, and exotic birds,” he tells me. My attention is drawn to the verb, “to see,” since my patient is in fact blind.
Before becoming ill, I painted every now and then. I took art lessons and visited as many museums as possible. Some 20 years ago, I went to the Vatican. Even now, I can see that seigniorial city, vividly, and revel in its architecture. I turn my attention to an altarpiece, carved in wood, but then I feel a tremendous temptation to make the altarpiece even more intricate. With enormous effort, I manage to gradually change the details of the altarpiece. I can recreate the entire structure of the Vatican. Sometimes I need many days to get it right.
January 13, 1999
I’ve dreamed that I embark with my friends on an excursion into the woods. I get lost and arrive at a lake. I climb a tree to leap over the water, but I find myself in an uncertain position. I’m unable to climb down, but I can’t continue climbing higher because the branches aren’t strong enough. I direct my sight to the lake: I see very large fish, primitive sharks, and manta rays. I fall and I wake up, but I can still see the creatures of my dream—the fish, the sharks, the manta ray—floating in the air, while I walk to the bathroom or the kitchen. Yet once I am awake, I know they are imaginary. This vision persists for an hour of wakefulness, beyond my control. For a while it’s amusing, but if it lasts too long it becomes unbearable.
January 14, 1999
I received a call from the neurosurgery department. Alejandro began screaming for help. A nurse found that his pulse was elevated; he was drenched with perspiration and was panting. The EEG study turned out to be normal. By the time I met him, he tried to laugh the matter off.
“I got scared by one of my visions.”
“But you often control them, isn’t that right?”
Almost always. I don’t know why, sometimes I feel an urge to shout or to flee, as if there were no air in the room… then I lose control over my visions. I see my grandmother, just the way I remember her when she died. I could still see in those days. Watching her in such a fragile situation hurt me very much. When the feelings of terror come, my agonizing grandmother may appear with great vividness. I have an urge to run away. But all around me, there are hundreds of hospital beds, and in every bed, I see my dying grandmother. Whenever my visions become uncontrollable, I use a trick: casing or framing the nightmarish images as if putting them on stage, or setting them on a theatrical dais, and next I invent some enormous curtains. I gradually bring the scene to a close by drawing in the curtains. If I draw them in too quickly, the trick never works. But if I do it gradually and try to relax, the nightmare vanishes, slowly, behind the curtain. Occasionally this trick is of no use, and no matter how slowly I draw in the curtains, my anguishing grandmother remains there, suspended.
January 18, 1999
I speak with my superior about this case of Charles Bonnet syndrome (1–3). Impatiently, he prescribes an antipsychotic medication. I raise the matter with Alejandro, but he considers the suppression of his images to be an act of barbarism. I cannot help but agree, in this instance. Alejandro needs the playful experience that renews his consciousness in the form of moldable hallucinations, often marvelous, sometimes terrifying. Fortunately, we have devised a pharmacological treatment for his anxiety states. Additionally, we agree that if he can learn to maintain a modicum of control over the emotional background, he might also gain control over the origin of the images and their phenomenology. A psychotherapeutic approach will be necessary to achieve this.
I guess Alejandro’s visual culture and former practice in plastic arts helped him to expand his capacities of visual working memory: this enables him to retain hallucinatory images for long periods and to transform these images, slowly, as works of art. Should I question the notion of hallucinatory states and think instead of a vivid imagination? However, salient emotional states may disrupt the patient’s executive control, and the images formed under such emotional score are involuntary, regarding both content and mechanism. Perhaps we agree at this point to call them hallucinations, once again. The introspection has started for both of us: Alejandro will try to learn to modulate the emotional source of his imagination. Myself, I am still searching for a scientific knowledge of subjectivity in the context of neurological disease: what are the boundaries between artistic imagination, reminiscence, dreams, and hallucination? How do we form a sense of agency regarding our own mental images?
Footnote
Translated by Eduardo Jiménez Mayo.
References
1.
Berrios GE, Brook P: The Charles Bonnet syndrome and the problem of visual perceptual disorders in the elderly. Age Ageing 1982; 11:17–23
2.
Teunisse RJ, Cruysberg J, Verbeek A, et al: The Charles Bonnet syndrome: a large prospective study in The Netherlands: a study of the prevalence of the Charles Bonnet syndrome and associated factors in 500 patients attending the University Department of Ophthalmology at Nijmegen. Br J Psychiatry 1995; 166:254
3.
Yoldi-Negrete M, Ramírez-Bermúdez J, Ruiz-Chow A, et al: Visual hallucinations in sensory deprived patients: Charles Bonnet syndrome? Salud Mental 2015; 38:217–224
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Accepted: 13 August 2018
Published in print: Spring 2019
Published online: 23 April 2019
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The author reports no financial relationships with commercial interests.
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