Hallucinations

10 Delirious

As a medical student at the Middlesex Hospital in London in the 1950s, I saw many patients with delirium, states of fluctuating consciousness sometimes caused by infections with high fevers or by problems like kidney or liver failure, lung disease, or poorly controlled diabetes, all of which may produce drastic changes in blood chemistry. Some patients were delirious from medications, especially those receiving morphine or other opiates for pain. Patients with delirium were almost always on medical or surgical wards, not on neurological or psychiatric wards, for delirium generally indicates a medical problem, a consequence of something affecting the whole body, including the brain, and it disappears as soon as the medical problem has been righted.

It may be that age, even when there is full intellectual function, increases the risk of hallucinations or delirium in response to medical problems and medication — especially with the polypharmacy so often practiced in medicine today. Working in a number of old-age homes, I sometimes see patients on a dozen or more different medications, which are liable to interact with one another in complex ways and, not uncommonly, tip the patients into delirium.[53]

We had one patient on a medical ward at the Middlesex Hospital, Gerald P., who was dying from kidney failure — his kidneys could no longer clear the toxic levels of urea building up in his blood, and he was delirious. Mr. P. had spent much of his life supervising tea plantations in Ceylon. I read this in his chart, but I could have gathered it from what he said in his delirium, for he talked nonstop, with wild associational leaps from one thought to another. My professor had said he was “talking nonsense,” and at first I could make little sense of what he was saying — but the more I listened, the more I understood. I started spending as much time as I could with him, sometimes two or three hours a day. I began to see how fact and fantasy were admixed in the hieroglyphic form of his delirium, how he was reliving and at times hallucinating the events and passions of a long and varied life. It was like being privy to a dream. At first he talked to no one in particular; but once I started to ask him questions, he responded. I think he was glad that someone was listening; he became less agitated, more coherent in his delirium. He died peacefully a few days later.

In 1966, when I started practice as a young neurologist, I began working at Beth Abraham Hospital in the Bronx, a home for those with chronic diseases. One patient there, Michael F., was an intelligent man who, besides other problems, had a very damaged, cirrhotic liver, the result of a severe hepatitis infection. The little liver he had left could not cope with a normal diet, and his protein intake had to be strictly limited. Michael found this hard to take, and every so often he “cheated” by eating some cheese, which he adored. But one day, it seemed, he went too far, for he was found in a near coma. I was called at once, and when I arrived, I found Mr. F. in an extraordinary state, alternating between stupor and delirious agitation. There were brief periods when he would “come together” and show insight into what was going on. “I’m out of this world,” he said at one point. “I’m stoned on protein.”

When I asked him what this state felt like, he said, “like a dream, confused, sort of crazy, spaced out. But I know I’m high, as well.” His attention seemed to dart about, touching on one thing and then another almost at random. He was very restless and had all sorts of involuntary movements. I had my own EEG machine at the time, and, wheeling that into Mr. F.’s room, I found that his brain waves were dramatically slowed — his EEG showed classic slow “liver waves” as well as other abnormalities. Within twenty-four hours of resuming his low-protein diet, though, Mr. F. was back to normal, as was his EEG.

Many people — especially children — experience delirium with a high fever. One woman, Erika S., recalled this in a letter to me:

Josée B. also wrote to me about her “Alice-in-Wonderland syndrome” as a child with fever. She remembered feeling “incredibly small or incredibly large and sometimes both at the same time.” She also experienced distortions in proprioception, her perception of her own body position: “One evening, I couldn’t sleep in my own bed — every time I lay down on it, I would feel I was standing tall.” She had a visual hallucination, too: “Suddenly I saw cowboys who were throwing apples at me. I jumped onto my mother’s dresser to hide behind a lipstick tube.”

Another woman, Ellen R., had visual hallucinations that took on a rhythmic, pulsing quality:

Sometimes in a delirium there may be a deep humming sound that waxes and wanes in a similar way.

While many people describe delirious swellings of body image, Devon B., when feverish, experienced mental or intellectual swellings instead:

This letter made me think of the arithmetical deliria which Vladimir Nabokov went through, wrestling with impossibly large numbers, as he described in his autobiography Speak, Memory:

Some people feel that the hallucinations and strange thoughts of delirium may provide, or seem to provide, moments of rich emotional truth, as with some dreams or psychedelic experiences. There may also be revelations or breakthroughs of deep intellectual truth. In 1858, Alfred Russel Wallace, who had been traveling the world for a decade, collecting specimens of plants and animals and considering the problem of evolution, suddenly conceived the idea of natural selection during an attack of malarial fever. His letter to Darwin proposing this theory pushed Darwin to publish On the Origin of Species the following year.

Robert Hughes, in the opening of his book on Goya, writes about a prolonged delirium during his recovery from a nearly fatal car crash. He was in a coma for five weeks and hospitalized for almost seven months. In intensive care, he wrote,

In this strange delirium, Hughes wrote, a transformed Goya seemed to be mocking and tormenting him, trapping him in some hellish limbo. Eventually, Hughes interpreted this “bizarre and obsessive vision”:

Alethea Hayter, in her book Opium and the Romantic Imagination, writes that Piranesi, the Italian artist, was “said to have conceived the idea of his engravings of Imaginary Prisons when he was delirious with malaria,” a disease he contracted

Delirium may produce musical hallucinations, as Kate E. wrote:

A number of people have written to me that they have visual hallucinations of music, hallucinating musical notation all over the walls and ceiling. One of them, Christy C., recalled:

Tactile hallucinations, too, can come with fever or delirium, as Johnny M. described: “When I had high fevers as a child I had very weird tactile hallucinations … a nurse’s fingers would switch from being beautiful smooth porcelain to rough, brittle-feeling twigs or my bed sheets would go from luscious satin to drenched, heavy blankets.”

Fevers are perhaps the commonest cause of delirium, but there may be a less obvious metabolic or toxic cause, as recently happened with a physician friend of mine, Isabelle R. She had had two months of increasing weakness and occasional confusion; finally she became unresponsive and was taken to the hospital, where she had a florid delirium, with hallucinations and delusions. She was convinced that a secret laboratory was hidden behind a picture on the wall of her hospital room — and that I was supervising a series of experiments on her. She was found to have extremely high levels of calcium and vitamin D (she had been taking large doses of these for her osteoporosis), and as soon as these toxic levels dropped, her delirium ceased, and she returned to normal.

Delirium is classically associated with alcohol toxicity or withdrawal. Emil Kraepelin, in his great 1904 Lectures on Clinical Psychiatry, included the case history of an innkeeper who developed delirium tremens from drinking six or seven liters of wine a day. He became restless and immersed in a dreamlike state in which, Kraepelin wrote,

The innkeeper had some delusions, too, perhaps produced by his hallucinations:

While deliria such as the innkeeper’s may be incoherent, without any theme or connecting thread, other deliria convey the sense of a journey, or a play, or a movie, giving coherence and meaning to the hallucinations. Anne M. had such an experience after she had run a high temperature for several days. She first saw patterns whenever she closed her eyes to go to sleep; she described them as resembling Escher drawings in their sophistication and symmetry:

These drawings were succeeded by richly colored images that reminded her of Brueghel paintings. Increasingly, these too became full of monsters and subdivided themselves, polyopically, into a cluster of identical mini-Brueghels.

Then came a more radical change. Anne found herself in the back of “a 1950s Chinese bus on a propaganda tour of Chinese Christian churches.” She recalls watching a movie on religious freedom in China projected onto the rear window of the bus. But the viewpoint kept changing — both the movie and the bus suddenly tilted to odd angles, and it was unclear, at one point, whether a church spire she saw was “real,” outside the bus, or part of the movie. Her strange journey occupied the greater part of a feverish and insomniac night.

Anne’s hallucinations appeared only when she closed her eyes and would vanish as soon as she opened them.[54] But other deliria may produce hallucinations that seem to be present in the real environment, seen with the eyes open.

In 1996, I was visiting Brazil when I started to have elaborate narrative dreams with extremely brilliant colors and an almost lithographic quality, which seemed to go on all night, every night. I had gastroenteritis with some fever, and I assumed that my strange dreams were a consequence of this, compounded, perhaps, by the excitement of traveling along the Amazon. I thought these delirious dreams would come to an end when I got over the fever and returned to New York. But, if anything, they increased and became more intense than ever. They had something of the character of a Jane Austen novel, or perhaps a Masterpiece Theatre version of one, unfolding in a leisurely way. These visions were very detailed, with all the characters dressed, behaving, and talking as they might in Sense and Sensibility. (This astonished me — for I have never had much social sense or sensibility, and my taste in novels inclines more to Dickens than Austen.) I would get up at intervals during the night, dab cold water on my face, empty my bladder, or make a cup of tea, but as soon as I returned to bed and closed my eyes again I was in my Jane Austen world. The dream had moved on while I was up, and when I rejoined it, it was as if the narrative had continued in my absence. A period of time had passed, events had transpired, some characters had disappeared or died, and other new ones were now on stage. These dreams, or deliria, or hallucinations, whatever they were, came every night, interfering with normal sleep, and I became increasingly exhausted from sleep deprivation. I would tell my analyst about these “dreams,” which I remembered in great detail, unlike normal dreams. He said, “What’s going on? You have produced more dreams in the past two weeks than in the previous twenty years. Are you on something?”

I said no — but then I remembered that I had been put on weekly doses of the antimalarial drug Lariam before my trip to the Amazon, and that I was supposed to take two or three further doses after my return.

I looked up the drug in the Physician’s Desk Reference — it mentioned excessively vivid or colorful dreams, nightmares, hallucinations, and psychoses as side effects, but with an incidence of less than 1 percent. When I contacted my friend Kevin Cahill, an expert in tropical medicine, he said that he would put the incidence of excessively vivid, colorful dreams closer to 30 percent — the full-blown hallucinations or psychoses were considerably rarer. I asked him how long the dreams would go on. A month or more, he said, because Lariam has a very long half-life and would take that long to be eliminated from the body. My nineteenth-century dreams gradually faded, though they took their time doing so.

Richard Howard, the poet, was thrown into a delirium for several days following back surgery. The day after the operation, lying in his hospital bed and looking up, he saw small animals all around the edges of the ceiling. They were the size of mice but had heads like those of deer; they were vivid: solid, animal-colored, with the movements of living creatures. “I knew they were real,” he said, and he was astonished when his partner, arriving at the hospital, could not see them. This did not shake Richard’s conviction; he was simply puzzled as to why his partner, an artist, could be so blind (after all, he was the one who was usually so good at seeing things). The thought that he might be hallucinating did not enter Richard’s mind. He found the phenomenon remarkable (“I’m not accustomed to things like a frieze of deer heads on mouse bodies”), but he accepted them as real.

The next day, Richard, who teaches literature at a university, began seeing another remarkable sight, a “pageant of literature.” The physicians, nurses, and hospital staff had dressed up as literary figures from the nineteenth century, and they were rehearsing the pageant. He was very impressed by the quality of their work, although he understood that some other observers were more critical. The “actors” talked freely among themselves, and with Richard. The pageant, he could see, took place on several floors of the hospital simultaneously; the floors seemed transparent to him, so that he could watch all the levels of the performance at once. The rehearsers wanted his opinion, and he told them he thought it very attractively and intelligently done, delightful. Telling me this story six years later, he smiled, saying that even recollecting it was a delight. “It was a very privileged time,” he said.

When real visitors came, the pageant would disappear, and Richard, alert and oriented, chatted with them in his usual way. But as soon as they left, the pageant recommenced. Richard is a man with an acute and critical mind, but his critical faculty, it seems, was in abeyance during his delirium, which lasted for three days, and was perhaps provoked by opiates or other drugs.

Richard is a great admirer of Henry James — and James, as it happens, also had a delirium, a terminal delirium, in December 1915, associated with pneumonia and a high fever. Fred Kaplan describes it in his biography of James:

This was recognized by others too — and it was said that though the master was raving, his style was “pure James” and, indeed, “late James.”

Sometimes withdrawal from drugs or alcohol may cause a delirium dominated by hallucinatory voices and delusions — a delirium which is, in effect, a toxic psychosis, even though the person is not schizophrenic and has never had a psychosis before. Evelyn Waugh provided an extraordinary account of this in his autobiographical novel The Ordeal of Gilbert Pinfold.[55] Waugh had been a very heavy drinker for years, and at some point in the 1950s he had added a potent sleeping draft (an elixir of chloral hydrate and bromide) to the alcohol. The draft grew stronger and stronger, as Waugh wrote of his alter ego, Gilbert Pinfold: “He was not scrupulous in measuring the dose. He splashed into the glass as much as his mood suggested and if he took too little and woke in the small hours he would get out of bed and make unsteadily for the bottle and a second swig.”

Feeling ill and unsteady, and with his memory occasionally playing tricks on him, Pinfold decides that a cruise to India might be restorative. His sleeping mixture runs out after two or three days, but his drinking stays at a high level. Barely has the ship got under way than he starts to have auditory hallucinations; most are of voices, but on occasion he hears music, a dog barking, the sound of a murderous beating administered by the captain of the ship and his doxy, and the sound of a huge mass of metal being thrown overboard. Visually, everything and everyone seems normal — a quiet ship with unremarkable crew and passengers, steaming quietly past Gibraltar into the Mediterranean. But complex and sometimes preposterous delusions are engendered by his auditory hallucinations: he understands, for example, that Spain has claimed sovereignty over Gibraltar and will be taking possession of the vessel, and that his persecutors possess thought-reading and thought-broadcasting machines.

Some of the voices address him directly — tauntingly, hatefully, accusingly; they often suggest that he commit suicide — although there is a sweet voice, too (the sister of one of his tormentors, he understands), who says she is in love with him, and asks if he loves her. Pinfold says he must see her, as well as hear her, but she says that this is impossible, that it is “against the Rules.” Pinfold’s hallucinations are exclusively auditory, and he is not “allowed” to see the speaker — for this might shatter the delusion.

Such elaborate deliria and psychoses have a top-down as well as a bottom-up quality, like dreams. They are volcano-like eruptions from the “lower” levels in the brain — the sensory association cortex, hippocampal circuits, and the limbic system — but they are also shaped by the intellectual, emotional, and imaginative powers of the individual, and by the beliefs and style of the culture in which he is embedded.

A great many medical and neurological conditions, as well as all sorts of drugs (whether taken for therapeutic purposes or for recreation), can produce such temporary, “organic” psychoses. One patient who stays most vividly in my mind was a postencephalitic man, a man of much cultivation and charm, Seymour L. (I refer to him and his hallucinations briefly in Awakenings). When given a very modest dose of L-dopa for his parkinsonism, Seymour became pathologically excited and, in particular, started to hear voices. One day he came up to me. I was a kind man, he said, and he had been shocked to hear me say, “Take your hat and your coat, Seymour, go up to the roof of the hospital, and jump off.”

I replied that I would not dream of saying anything like that to him, and that he must be hallucinating. “Did you see me?” I continued.

“No,” Seymour answered, “I just heard you.”

“If you hear the voice again,” I said to him, “look round and see if I am there. If you cannot see me, you will know it is a hallucination.” Seymour pondered this briefly, then shook his head.

“It won’t work,” he said.

The next day he again heard my voice telling him to take his hat and his coat, go up to the roof of the hospital, and jump off, but now the voice added, “And you don’t need to turn round, because I am really here.” Fortunately, Mr. L. was able to resist jumping, and when we stopped his L-dopa, the voices stopped, too. (Three years later, Seymour tried L-dopa again, and this time he responded beautifully, without a hint of delirium or psychosis.)