Complex visual hallucinations in the visually impaired - A structured history-taking approach

Objective: To study complex visual hallucinations in visually impaired individuals. Methods: A prospective comparative study involving structured history taking and cognitive assessment in 48 consecutive visually impaired individuals with best-corrected visual acuity of 20/200 or worse and an age-matched cohort of 48 consecutive patients with visual acuity of 20/40 or better in at least 1 eye. Results: Thirty visually impaired subjects (63%) experienced hallucinations, unrelated to specific ocular pathology. None volunteered the symptom; 2 admitted hallucinations on nonleading questioning and 28 on direct questioning. All displayed insight into the unreality of their hallucinations, although 18 (60%) achieved this after initial deception. Seventeen (57%) expressed concern; 7 (23%) experienced disturbing images. Nineteen (63%) feared being labeled as insane were they to admit to hallucinations, while 10 (33%) were fearful of impending insanity. Sixteen (94%) of 17 concerned patients derived comfort from sympathetic reassurance that their hallucinations did not represent sinister pathology. In contrast, none of the individuals with normal vision experienced any hallucinations (P<.001). Cognition was intact in all groups. Conclusions: Complex visual hallucinations with insight commonly occur in visually impaired, cognitively intact individuals due to acquired visual impairment and are unrelated to chronological age. Hallucinatory experiences are almost invariably admitted to only on direct questioning, due to fears of being considered insane. Although generally pleasant, hallucinations may cause distress, because of content or implications of the hallucinatory activity. Sympathetic explanation affords significant emotional relief.