Visions of Little People

Richard Westman was a fine-boned, soft-spoken eighty year old retired accountant, who prided himself of his sharp intellect and excellent memory. I had known him for a few years, but didn’t see him often as he was relatively healthy. Then a myocardial infarction robbed him of his physical stamina, and he started to develop heart failure. He also developed heart rhythm problems, and ended up with a pacemaker and on a blood thinner. We saw a lot of each other during the last two years of his life – or I saw more of him than he saw of me, as he suffered from advancing macular degeneration.

He was familiar enough with our office layout that a casual observer might not have noticed how visually impaired he was. He needed help managing his medication bottles, and he had long before lost his ability to read and watch television. He listened to books on tape, and he followed the news with great interest; there was nothing wrong with his mind, or so I thought.

Then one day he confided in me that he saw things – children, sometimes groups of them, playing in the yard outside his kitchen window in broad daylight. They always seemed friendly and happy, never threatening. They never spoke, never made a mess and never pulled any pranks.

At first he was unnerved by seeing them, but gradually he came to enjoy their presence. He confided in me:

“I don’t really think they are there, but I don’t know why I see them.”

“Do you want them to go away?” I asked.

“No, they just puzzle me” was his answer.

I had at first thought of offering him a trial of a mild antipsychotic, but it was clear that he didn’t need that, since the visions didn’t frighten him in any way.

We talked about the children now and then, but I soon forgot about his visions. Then one day his wife called the office and said their daughter had found something on the Internet they wanted me to read. The had figured out that Mr. Westman suffered from Charles Bonnet Syndrome, CBS.

Most of the time it isn’t a thrill when patients or their families bring in articles they have found online. We all know that more information is not the same as better information. But this time I was fascinated by what they brought to my attention, and I soon found myself digging deeper into the subject on my own:

First described in 1760 by a Swiss philosopher, who noticed that his grandfather, who was almost blind, saw birds and other figures that weren’t there, Charles Bonnet Syndrome (CBS) typically affects older people with severe vision loss. CBS often only exists for a year or two as vision deteriorates, and can involve geometric patterns or little creatures, often elf-like, usually friendly looking and often with hats. The visions are rarely threatening and they are common – at least 10% of people with worse than 20/60 vision are said to have this syndrome.

CBS is not a psychological condition. It is believed to be something similar to phantom pains, where a person even after an amputation can “feel” a missing extremity, even though they know perfectly well that it isn’t there. The visual cortex of our brains is always “filling in the blanks” when we look at something quickly or when we cannot see things quite clearly. Any type of visual impairment, such as cataracts, diabetic retinopathy or macular degeneration, can create more “blanks”, which are automatically “filled in” by the brain. Antipsychotics don’t seem to be of any help.

Some writers like to think of Charles Bonnet Syndrome as a portal to paranormal experiences or parallel universes. For me it was a portal to being more willing to see what patients and their families drag into the office after surfing around the Internet!

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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