we do bones motherfucker

A difficult case

Diagnosis made by hallucinatory voices

Ikechukwu Obialo Azuonye

A previously healthy woman began to hear hallucina-

tory voices telling her to have a brain scan for a

tumour. The prediction was true; she was operated on

and had an uneventful recovery.

No previous illnesses

Born in continental Europe in the mid-1940s the

patient settled in Britain in the late 1960s. After a series

of jobs, she got married, started a family, and settled

down to a full time commitment as a housewife and

mother. She rarely went to her general practitioner as

she enjoyed good health and had never had any hospi-

tal treatment. Her children had also been in good

health.

In the winter of 1984, as she was at home reading,

she heard a distinct voice inside her head. The voice

told her, “Please don’t be afraid. I know it must be

shocking for you to hear me speaking to you like this,

but this is the easiest way I could think of. My friend

and I used to work at the Children’s Hospital, Great

Ormond Street, and we would like to help you.”

AB had heard of the Children’s Hospital, but did

not know where it was and had never visited it. Her

children were well, so she had no reason to worry

about them. This made it all the more frightening for

her, and the voice intervened again: “To help you see

that we are sincere, we would like you to check out the

following”—and the voice gave her three separate

pieces of information, which she did not possess at the

time. She checked them out, and they were true, but

this did not help because she had already come to the

conclusion that she had “gone mad.” In a state of panic,

AB went to see her doctor, who referred her urgently

to me.

I saw her at the psychiatric outpatients clinic, and

diagnosed a functional hallucinatory psychosis. I

offered general supportive counselling as well as

medication with thioridazine. To her great relief, the

voices inside her head disappeared after a couple of

weeks of treatment, and she went off on holiday. While

she was abroad, and still taking the thioridazine, the

voices returned. They told her that they wanted her to

return to England immediately as there was something

wrong with her for which she should have immediate

treatment. By this time, she was also having other

beliefs of a delusional nature.

She returned to London and I saw her again at my

outpatients clinic. By this time, the voices had given her

an address to go to. Reluctantly, and just to reassure her

that it was all in her mind, her husband took her by car

to the address in question; it was the computerised

tomography department of a large London hospital.

As she arrived there, the voices told her to go in and

ask to have a brain scan for two reasons–she had a

tumour in her brain and her brain stem was inflamed.

Because the voices had told her things in the past that

had turned out to be true, AB believed them when they

said that she had a tumour and was in a state of great

distress when I saw her the next day.

Brain scan requested

In order to reassure her, I requested a brain scan,

explaining in my letter that hallucinatory voices had

told her that she had a brain tumour, that I had not,

personally, found any physical signs suggestive of an

intracranial space occupying lesion, and that the

purpose of the scan was essentially to reassure the

patient. The request was initially declined, on the

grounds that there was no clinical justification for such

an expensive investigation. It was also implied that I

had gone a little overboard, believing what my patient’s

hallucinatory voices were telling her.

Eventually, after some negotiation, the scan was

done in April. The initial findings led to a repeat scan,

with enhancement, in May, revealing a left posterior

frontal parafalcine mass, which extended through the

falx to the right side. It had all the appearances of a

meningioma.

The consultant neurosurgeon to whom I referred

AB noted the absence of headache or any other focal

neurological deficits related to this mass, and discussed,

with AB and her husband, the pros and cons of imme-

diate operation as against waiting for symptoms to

appear. In the end, it was agreed to proceed with an

immediate operation. AB’s voices told her that they

were fully in agreement with that decision.

These were the notes of the operation, carried out

in May 1984: “A large left frontal bone flap extending

across the midline was turned following a bifrontal skin

flap incision. Meningioma about 2.5” by 1.5” in size

arose from the falx and extended through to the right

side. A small area of tumour appeared on the medial

surface of the brain. The tumour was dissected out and

removed completely along with its origins in the falx.”

AB later told me that when she recovered

consciousness after the operation the voices told her,

“We are pleased to have helped you. Goodbye.” There

were no postoperative complications. The dosage of

dexamethasone was halved every four days, and then it

was stopped. She was on prophylactic anticonvulsants

for six months. Antipsychotic medication was discon-

tinued immediately after the operation, and there was

no return of the hallucinatory voices or the delusions

which she had expressed.

Discussion

AB telephoned me last Christmas to wish me and fam-

ily a merry festive season, and to tell me that she had

been completely well in the 12 years since the

operation. It was this telephone call that brought this

case to mind again.

It is well known that intracranial lesions can be

associated with psychiatric symptomatology. But this is

the first and only instance I have come across in which

hallucinatory voices sought to reassure the patient of

their genuine interest in her welfare, offered her a spe-

cific diagnosis (there were no clinical signs that would

have alerted anyone to the tumour), directed her to the

type of hospital best equipped to deal with her

problem, expressed pleasure that she had at last

received the treatment they desired for her, bid her

farewell, and thereafter disappeared.

I presented her case at a conference later that year.

AB attended and was closely questioned by several

people about the various aspects of her experience.

The audience was split down the middle. People who

would be called X-philes today rejoiced that what had

happened to her was a clear instance of telepathic

communication from two well meaning people who

had, psychically, found that AB had a tumour and

sought to help her.

The X-phobes had a very different formulation.

According to them, AB had been given the diagnosis of

a brain tumour in her original country and wanted to

be treated free under the NHS. Hence, they surmised,

she had made up the convoluted tale about voices tell-

ing her this and that. But AB had lived in Britain for 15

years and was entitled to NHS treatment. Besides, she

had been so relieved when the voices first disappeared

on thioridazine that she had gone on holiday to

celebrate the recovery of her sanity.

There was a group at the case conference who

offered a different opinion. Their view was that, the

total lack of physical signs notwithstanding, it was

unlikely that a tumour of that size had had absolutely

no effect on the patient. “She must have felt

something,” they argued. They suggested that a funny

feeling in her head had led her to fear that she had a

brain tumour. That fear had led to her experience of

hallucinatory voices. She may have unconsciously

taken in more information about various hospitals

than she realised, and this information was reproduced

by her mind as part of the auditory hallucinatory

experience. The voices expressing satisfaction with the

outcome of her treatment were her own mind express-

ing its relief that the emergency was over. And the total

disappearance of psychiatric symptoms after the

removal of the tumour showed that these symptoms

were at least directly related to the presence of the

lesion–and may, in fact, have been produced by the

lesion itself. I have obtained the patient’s signed