[Full text] A difficult case: Diagnosis made by hallucinatory voices
DOI:10.1136/bmj.315.7123.1685
Authors: Ikechukwu Obialo Azuonye (Oxleas NHS Foundation Trust)
A previously healthy woman began to hear hallucinatory voices telling her to have a brain scan for a tumour. The prediction was true; she was operated on and had an uneventful recovery.
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 hospital 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, โPlease 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.โ
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: โTo help you see that we are sincere, we would like you to check out the followingโโand 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 โgone mad.โ 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 reasonsโshe 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.
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 immediate 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: โA large left frontal bone flap extending across the midline was turned following a bifrontal skin flap incision. Meningioma about 2.5โ by 1.5โ 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.โ
AB later told me that when she recovered consciousness after the operation the voices told her, โWe are pleased to have helped you. Goodbye.โ 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 discontinued immediately after the operation, and there was no return of the hallucinatory voices or the delusions which she had expressed.
AB telephoned me last Christmas to wish me and family 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 specific 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 telling 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. โShe must have felt something,โ 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 expressing 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 lesionโand may, in fact, have been produced by the lesion itself. I have obtained the patient's signed consent to publication.
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