Wednesday, March 30, 2011

Hallucinations in non-psychotic people

In the Seventies when I was doing my residency patients would get diagnosed as schizophrenic at the drop of a hat. Added to this was the evidence-based science of that era which proclaimed that "Once a schizophrenic always a schizophrenic."

Schizophrenics never recovered was the dictum. And they really believed in this self-serving medical fact.  To complete this demonic vision of the illness, the psychiatrists in those days took awful pride in being the kind of guy who did not flinch at prescribing gargantuan dosages of antipsychotics. It is not surprising the hospitals overflowed with patients who did nothing but drool and do the Thorazine shuffle, lending further evidence to the "evidence-based" scientific thinking of those days that schizophrenia was a life long malady.

And a single confession of hearing voices could garner the diagnosis.

Over the years I have done Disability Determination evaluation for Social Security in poor sections of Detroit, examining hundreds of African-American patients and have been struck by as to how often they report presence of hallucinations. And it hardly seems to be confined to those suffering from psychosis.  Hallucinations in general is more prevalent in African American patients than whites even when they are suffering from identical psychotic illness.  But it was an eye opener as to how many non-psychotic African-American patients also report hallucinations.

I came across two such patients today reporting of which may have some scientific value.

Case I


A 59 year old African-American woman who is severely depressed and does not leave her room since her 18 year old son was shot dead emerging from a grocery store, reported that she sees her son every day.

When asked where does she see him, she replied, "Standing at the door of my bedroom." And for how long, she replied, "Ten minutes. And he is clear as can be, and looks straight at me." When asked does he talk she replied, "He tells me he is alright. Sometimes he tells me I am still with you."

This assurance was easily analyzed as her extreme desire to know that he is happy wherever he is for she cannot forgive herself for not protecting him from death. He was her favorite child. "He was Momma's boy, who hung around me more than any of my other children."

She was in the vicinity of the grocery store where he was killed, and had actually heard the gunshots that had bled him to death, and though came quickly to where the shooting occurred, he was already unresponsive.  When she heard the gunshots, something told her that it was him getting shot and so she feels guilty that somehow she had a role in his death. Furthermore she feels that it was a failure on her part that the killers could not be brought to justice, though nobody found the assailant/s, or even discovered the motive of the crime.
So hearing the dead boy telling her in the vision that he is alright acts as a balm to her sense of guilt.

This motive to create hallucination to feel less guilty I saw in another girl, whose sister died in a car accident, and the reality of whose death she constantly forgets, often living in the make-belief that her sister is still alive. This 17 year old girl, one night woke up to find her sister lying next to her in bed. The sister said, "Sister it is not as bad here as you think," and then disappeared.

In both cases the hallucinations were produced to assuage the guilt over the death and a need for the reassurance that the dead person is not suffering but is happy.

Case II


An 18 year old African American boy reported that his father, while in the hospital for collapsed lung and pneumonia, on brink of death, had an extraordinary out-of-body experience. He died for 20 seconds, which was, per patient, confirmed by his brother and sister. When asked how did they know he was dead, the boy stated that his father rolled up his eyes, which is a sure sign of dying.

The boy then narrated to me what his father experienced while he was dead. It was like a blackout in which he came out of his body and saw himself lying dead on the hospital bed. While hovering he cried out that his time is not due yet. He then heard a voice, "Yes, his time is not due yet."

The voice caused his soul to immediately return to his body. The father swears by the reality of the voice and the brothers and sister insist that he was definitely dead for 20 seconds.

Now here is a shared magical thinking. To call it shared psychosis would not be correct.

But there is no doubt this was a hallucinatory experience.

Why did it happen?

Perhaps the man had two contradictory wishes towards death. One was to get it over with it and embrace eternal peace and the other was that he still has unfinished business in this life. His youngest child is just 18, and very much vulnerable to harshness of this exploitative world, about which the father worries. And anyway the desire to cling to life is perhaps the strongest drive in all organisms, and is given up only when there is complete hopelessness. So he cried that his time is not due yet, and heard the projection of his own father's voice, telling him that his time is not due yet.

Do white people have hallucinations without psychosis? Yes, they do, but not that often.

Here is one case.

A 47 year old man, in midlife crisis, in throes of severe agitated depression, that was precipitated by the closing down of the machine shop in which he had worked for 20 years, and with his particular skill no longer in demand was faced with the prospect of working for minimum wages, which his pride would not let him, for he was used to making over 25 dollars an hour, and his finances dwindling to the point of having literally no food in the house to feed his wife and children, went into severe panic attacks, insomnia and nasty mood towards everybody.

He had the following two hallucinations.

My mother, who is now dead for over 15 years, is sitting across the room looking her usual no-nonsense West Virginian self. She makes an admonishing sign at me with her index finger. As usual a smoking cigarette is on her mouth.


The hallucination was easy to interpret and actually done by the patient himself. "I was seriously contemplating suicide or just walking out on my family for they would be better off without me. My mother who did everything by the book once told me that departed souls are allowed one visit from the beyond was using that one-time privilege to save me. And the motion of her finger was admonishment to not give up on living and that walking out on my children was not an option."

It is interesting that this patient's father had walked out on the family when he was a child. And his mother had brought him up. Taking advantage of life's adversities, he was trying to do to his kids what his father had done to him.

The second hallucination which took place a few weeks later was about his best friend.

I see this friend of mine sitting next to me. He was as real as you. He inquired after Mom and Dad and then asked, "How have you been. I have missed you." I told him, "I am going fucking nuts." Then I went to the kitchen to get coke and when I came back he was gone.


The person who appeared was his best friend and someone he grew up with and whose opinion he valued. One day he visited his friend, who was just 29 then, and while he went to get some coke in the kitchen, he heard a thud, and rushed back to his friend, who was lying on the floor his eyes showing no life. He had been struck dead by a ruptured brain aneurysm. The patient attributed the hallucinatory return of his friend from the dead to tell him as to how fragile and valuable life is and even if he is going nuts it is better to be nuts than be amongst the dead.

 He added that his mother and his friend were the two most important people in his life. It was not difficult to analyze that when life became unbearable it was natural that he thought of joining them. But in the hallucination his good sense made them reject this desire of his and tell him that he should return to his family and that being alive however miserable is better than being dead.

In all the above hallucinations a common thread is of death and of departed people. It appears that dead people are made to return as hallucinations to help the person in dealing with life's difficulties. So many of the African-American patients I have evaluated and who report hallucinations on further questioning report that the people who they see or feel the presence of are those who had been kind and helpful to them when they were alive. A beloved grandmother, or a favorite aunt, or some other parental substitute becomes one's constant companion and takes on hallucinatory proportions when under extreme stress. Not too different than how a child who feels helpless creates an imaginary friend whom he always carries around with him.
However, it is not always that hallucinatory figures are there to be a helpful companion. Sometimes one may bring a dead person back to life to help him or her from a difficult situation where one could not help when it was actually occurring.

A 19 year old girl reported hallucinations of seeing her mother screaming and yelling for help. The mother had died when the girl was barely 12. In those 12 years she had frequently and helplessly witnessed her mother being subjected to brutal beatings by her stepfather. Now when she was grown up enough to fight back with her stepfather and protect her mother, her mother was already dead. The vow to protect her mother could now be filled only in her hallucinations.

In an even more moving account of a hallucination I heard from an African-American woman, whose 18 year old son was shot right in front of their house. In fact he was shot 8 times, and as he bled from all over his body, he turned to his mother and beseeched her with his last breath,"Don't let me die on the street mother. I want to die in my bed."

"He did no harm to nobody. Why did they shoot my baby?" the mother cried once again in the interview.

His last words, "Don't let me die on the street mother. I want to die in my bed," keep echoing in her head and sometimes turn in to hallucinations.

The motive behind the hallucination, besides to see her son alive again, was the praise for her son's indomitable spirit, which even seconds before dying expressed his desire to be triumphant, having a say on the manner of his death, opting for his own bed and its security over the contemptuous, dirty, dangerous street.

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