When the Eyes Play Tricks: Charles Bonnet Syndrome Explains Visual Hallucinations in Those With Visual Impairments

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Mary D'Apice

Editor's note: Information about Charles Bonnet Syndrome is of major interest to our visitors. It is often misunderstood by people experiencing the visual hallucinations and by professionals. So Mary D'Apice, VisionAware peer adviser, decided to share Dolores's story to enlighten readers.

Visual Hallucinations

One night, 75-year-old Dolores woke up to find a huge tree growing beside her bed. Dolores is not a character out of a fiction story but one of many individuals who experience visual hallucinations brought on by vision loss. Dolores later learned the name for this phenomenon, "Charles Bonnet Syndrome". At the time she had no idea what was happening when the tree made her jump. "The image was very real to me, like it was in 3-D. I can still picture it." Soon she was regularly seeing pretty flowers popping up out of walls but none of her visions scared her. "I never saw anything frightening, like creepy crawlies."

When she told her retinal specialist about the experience, the concerned doctor ordered an MRI and referred her to a psychologist who later reported that "her brain was just fine." Not until Dolores attended her low vision support group did she discover the hallucinations were linked to her worsening eyesight caused by macular degeneration. Charles Bonnet Syndrome was named for the Swiss naturalist and philosopher who first described his grandfather's visions of carriages, birds and buildings in 1760. Dolores later returned to her retinal specialist with literature on Charles Bonnet. "He's an excellent doctor, but he had never heard anything about it."

Importance of Understanding Charles Bonnet

Dr. Susan Hirshfield, clinical psychologist and Living Skills Specialist at the Earle Baum Center, is not surprised that much of the medical community is unaware of the syndrome. "I had a family thinking their mother was psychotic." Thanks to her intervention, the woman was weaned off the unnecessary anti-psychotic medications that were making her sick. While such misdiagnoses may be rare, it's no wonder people are reluctant to admit that they've seen monkeys in the kitchen or skyscrapers in the backyard.

Twelve years ago, Dr. Hirshfield was unfamiliar with the syndrome, but as a clinical psychologist, she had an intuitive understanding that some visual hallucinations were not necessarily a sign of mental illness or dementia. She met Martha, an older, totally blind woman, who was seeing images of maps floating in the air. Martha's eyes had been enucleated (surgically removed) due to an illness. When asked what the maps meant to her, Martha said that she and her husband used to drive across- country and she navigated. Hirshfield got to the heart of the matter by discovering that maps symbolized happiness and adventure. "I realized that her brain was trying to understand not seeing," says Hirshfield. "It was offering something familiar and enjoyable to look at in the absence of any real visual input." Martha also enjoyed other visions, such as an image of sunlight dancing on the colors of a rug, which hung on a clothesline. "It's much better than the blackness," Martha told Hirshfield.

Martha's experience inspired Hirshfield to research and confirm that this was a neurological anomaly akin to phantom limb syndrome. "The brain cannot accommodate having the feeling that the eyes are open, the individual is out and about, fully awake but not seeing." Hirshfield points out that this does not happen to people who were born blind because the hallucinations are fed by visual memories.

Participants in Hirshfield's Living with Vision Loss class are forewarned that they may be visited by Charles Bonnet. For those who have already had surreal experiences, the news comes as a relief. Just last week, Hirshfield said 5 out of 15 attendees reported having had visual hallucinations. "One woman literally put her hand to her heart and said, 'I am so glad that you told us about this because I thought I was going nuts!'"

Because Hirshfield ensures that everyone at her agency is aware of Charles Bonnet, an Orientation and Mobility Instructor was able to put her client at ease when she had a visual hallucination during a training session. Cindy, who has glaucoma, had been learning to rely less on her diminished eyesight and to trust her white cane instead. One particular day, Cindy was terribly distracted by plants and rocks in the middle of the sidewalk. Though her instructor encouraged her not to use her vision she couldn't seem to navigate around the unexpected obstacles. "I was so stressed out that I ended up in tears." Cindy recalls. They walked to a cafe where Cindy was able to calm herself and have lunch with her instructor. Though she couldn't see clearly, Cindy could tell there were musical instruments, flags and other decorations on the vibrant, red walls. Relaxed, Cindy left the restaurant with her instructor.After walking a few blocks the festooned red walls of the restaurant suddenly appeared in front of her like a mirage. To Cindy's relief, the instructor told her about Charles Bonnet which explained not only the restaurant walls but the rocks and plants that her cane had been unable to detect earlier.

It was only in retrospect that Cindy realized she'd been having visual hallucinations for some time but because the were in the realm of normal experience, she hadn't paid much attention. At last, it made sense that she saw green hillsides covered with vineyards out the car window when she was actually driving through the suburbs. "There was only one time I felt betrayed by the visions," said Cindy. She returned to Pier One to buy a lamp she had seen previously but no one in the store could recall such a lamp. "I realized it was a Charles Bonnet moment." She laughs, "He tricked me!"

When the visions are disturbing, Hirshfield teaches people how to live with them. She tells the story of Ann, who would walk into her living room and find it full of strangers. Hirshfield had Ann make a large sign in bold, black ink that read "Touch them." She instructed her client to tape the sign to her bedroom door, her refrigerator, her bathroom mirror and all over the house. "Once she could reach out and had tactile connection with the fact that there wasn't anything there the image went away. Eventually she was able to comfort herself knowing there only she and her dog were in the house."

Advice on the Experience of Charles Bonnet

Vision loss disproportionately affects seniors, so many people with Charles Bonnet are older. Neither age nor type of visual impairment makes an individual more or less prone to seeing visions. "Bonnet is an equal opportunity trickster," says Hirshfield, who tries to normalize the experience. With knowledge, most handle the visions and even find them pleasurable. "Like something that was provided to entertain me," Cindy says.

"The syndrome is harmless so don't panic," Dolores advises. "The visions may come and go. Mine lasted a few months and stopped," an experience typical of many with Charles Bonnet. "The flowers and trees I see now are real and out in the yard!"

Macular Degeneration
Low Vision
Retinitis Pigmentosa
Support Groups
There are currently 9 comments

Re: When the Eyes Play Tricks: Charles Bonnet Syndrome Explains Visual Hallucinations in Those With Visual Impairments

My husband also has Charles Bonnet syndrome. I read an article that for some people blinking would make them go away. My husband tried that and it works most of the time. Some times he has to blink several times. For instance, He say ants crawling all over his food. He blinked once and some of them were gone. He blinked a couple more times and they all disappeared.

Re: When the Eyes Play Tricks: Charles Bonnet Syndrome Explains Visual Hallucinations in Those With Visual Impairments

We also heard that GABAPENTIN has been useful in eleminating the hullicinations. My husband has been on it for about 6 weeks, and the hallucinations have finally gone away.

Re: When the Eyes Play Tricks: Charles Bonnet Syndrome Explains Visual Hallucinations in Those With Visual Impairments

Great post! I was somewhat familiar with this and after reading I know and understand a lot more.

Re: When the Eyes Play Tricks: Charles Bonnet Syndrome Explains Visual Hallucinations in Those With Visual Impairments

I had first experienced Charles B several years ago I would wake up from deep sleep seeing birds flowers and such fire engines I have I was blinded in 1969 but retain partial vision than went from 20/700 to finger vision I paced the floor and became depressed I saw two little blond girls whose eyes followed me as they floated across my field of view a VA vision specialist immediately knew what I was experiencing and told me what a relief

Re: When the Eyes Play Tricks: Charles Bonnet Syndrome Explains Visual Hallucinations in Those With Visual Impairments

Interesting article. I never heard of this condition and from time to time I too have experienced seeing things that weren't actually there but I chalked it up to floaters or other issues with my vision. I'd like to dig deeper into this syndrome. Thank you for sharing.

Re: When the Eyes Play Tricks: Charles Bonnet Syndrome Explains Visual Hallucinations in Those With Visual Impairments

I started experiencing hallunations about a year ago. I had no idea what they were and felt like I was losing my mind. I was actually afraid to say anything to a Doctor about this for fear they would think that I was a nut case and start putting me on all kinds of medications....and I not sure that I wasn't a nut case but fear being evicted if my Manager found out stating that she didn't believe that I should be living alone without any family or friends to help.
I did finally mention it on a blind group on Facebook and someone came back and told me about this syndrome. Never in my wildest dreams did I think to even ask the eye Doctor as I thought that I needed a shrink.
It was explained to me that just as a person who has had a leg or an arm amputated and they fell fathom pain....so the brain still tries to see what the eye once used to. I was so relieved once I learned about this. I never saw anything scary, it was always comforting visions but it still scared me. The difference between someone that has a psychological issue is that the person doesn't know that the hallucination they are seeing is not real where as the person with this syndrome is aware that that tree is not in the middle of the bedroom.
I'm just glad that I now know about this.

Re: When the Eyes Play Tricks: Charles Bonnet Syndrome Explains Visual Hallucinations in Those With Visual Impairments

I wonder if that is what I am having,,,,I have cataracts but specialist says they aren't bad enough yet to have them removed. Even though he said they are contributing to my eyes blurring and lights blind me at night when I drive. I asked him if the cataracts can make me hallucinate? I was driving down a road and up ahead about a block and a half, I could see what look like a big crate sitting in the road, so I got over a lane, but when I got closer, there was nothing there. The specialist said I have astigmatism in my right eye that may have cause that,,,just don't look so far a head, was his advice. I thought, really!!! I think that is part of being a defensive driver, looking at what is up ahead not just what is in front of you. This isn't the first time I've seen things that weren't there. Mine are usually farther a head and when I get closer, I can see there is nothing there at all. Or is this part of the cataracts or something else!?

Re: When the Eyes Play Tricks: Charles Bonnet Syndrome Explains Visual Hallucinations in Those With Visual Impairments

The description of CBS compares it to phantom-limb pain in amputees and that sounds about right to my uneducated mind. I cannot say I have experience CBS precisely, but long after I became completely color-blind I was still perceiving store logos in the colors I recalled and lawns appeared green (even if they were brown, unfortunately!), etc. I chalked this up to my mind "filling-in-the-blanks" during the adjustment period.

Re: When the Eyes Play Tricks: Charles Bonnet Syndrome Explains Visual Hallucinations in Those With Visual Impairments

Doctors should tell macular degeneration patients about this. Thankfully, I read about it before I experienced this.

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