As a geriatric mental health nursing consultant to long-term care facilities, I am often asked to intervene with "problem behaviors" exhibited by residents. Among the most commonly reported problems are psychotic behaviors, especially hallucinations and delusions. (Simply put, hallucinations are defined as "seeing, hearing, smelling, tasting, or feeling things that are not really there," and delusions are "false ideas or beliefs that are maintained in spite of obvious proof of their inaccuracies.") This column will remind gerontological nurses that not all of their patients who are "seeing and hearing things" are mentally ill. In fact, they may be experiencing the littleunderstood phenomenon of "phantom seeing and hearing."
Like phantom limbs, phantom seeing and hearing experiences are generated by the brain in the absence of sensory input and can result in detailed and vivid sensory experiences (Melzack, 1992). When the brain loses its normal input, cells in the central nervous system become more active and the brain's intrinsic mechanisms transform that neuronal activity into meaningful sights and sounds (Melzack, 1992). Although the syndrome was first described in 1769 by Bonnet, it is still misunderstood, resulting in elderly patients being mislabeled as mentally ill and often inappropriately given psychotropic medications.
The elderly are especially vulnerable to phantom seeing and hearing, as they are most likely to suffer from impaired vision or hearing, such as from cataracts, macular degeneration, or tinnitus. Melzack (1992) reports that approximately 15% of persons who lose all or part of their vision report phantom visual experiences, although the actual number may be higher; many people are understandably reluctant to report the symptom for fear of being labeled "crazy."
Phantom visual episodes appear suddenly, come and go unexpectedly when the eyes are open, and are described as vivid and real, although the person experiencing them knows that they are not (Melzack, 1992). The images tend to be of people, buildings, or animals, and are not simply memories of past events - the phantom vision may never have been encountered before. Not surprisingly, the first appearance of these phantom visions is startling to the individual.
Phantom sounds are also common among persons who have lost their hearing, although they are seldom recognized for what they actually are, according to Melzack (1992). The sounds can be loud and unpleasant (like roaring or screeching) or soothing and musical, and, like phantom visions, are extremely real. Interestingly, persons who have both impaired sight and hearing may experience both phantom sounds and vision, often in a coordinated scenario.
Mrs C was an 88-yearold widowed nursing home resident who was nearly blind and could only make out shadows. She was, however, cognitively intact and enjoyed listening to talking books, conversing with visitors, and reminiscing about her exciting life. Although British, she had been born and raised on a Nicaraguan coffee plantation and had lived literally all over the world, having served as a nanny to wealthy families in New York, India, and Rome. Together we created a fascinating oral history for her nieces and nephews, as she had married late in life and had no children of her own.
The nursing home staff had initially asked me to see Mrs C because of her "visual hallucinations." When I queried her about "seeing things," she described the following scene in vivid detail. The image would come and go unexpectedly, and had become more frequent as her eyesight became progressively worse over the past year. It was almost always the same scene: a World War I French battleground where her former fiancé (who had been killed in the war) was stationed with his battalion. Mrs C described in exquisite detail the landscape (which she had never seen), the soldiers' khaki uniforms, and even noted how the horses' lips curled when they whinnied, as if to laugh at her for being so startled by the sight of the vision.
"Can't you see them - the horses and men over there on the wall?" she would ask. "Oh, they seem so real to me." Although somewhat amazed by her vision, Mrs C was not particularly frightened or troubled by it and clearly understood that she was the only person able to see it.
I was unaware of the phenomenon of phantom seeing and hearing at the time of my consultation, although I recommended to the staff that they not start Mrs C on any antipsychotic medications because the "visions" were not bothering her. I suggested to Mrs C that she disclose her visions only to persons she considered "safe," such as trusted staff members and family, to avoid upsetting others unnecessarily.
Since that time, I have done more reading about the brain and sensory input and came across Melzack's (1992) article, which introduced me to the concept of phantom seeing and hearing. I am convinced that Mrs C (and probably many other nursing home residents) was experiencing phantom seeing. And I urge gerontological nurses to carefully reassess their socalled "psychotic" patients to see if this illusive phenomenon might be present in their patients as well. This is one "phantom" that deserves to be exposed.
- Melzack, R. Scientific American 1992; April:120-126.