The Witch in the Waiting Room: A Physician Investigates Paranormal Phenomena in Medicine

by Robert S. Bobrow M. D. M. D.

  In these two cases, a structural lesion within the brain caused the problem. Entities like tumors, infections, or bleeding can occasionally cause hallucinations, and the location of the damage may determine the type. Hearing music, for instance, is more likely with lesions near the hearing centers. But structural damage usually causes more than just hallucinations. The fifty-seven-year-old man had numbness of one side of his body, with partial paralysis. The thirty-four-year-old had seizures and abnormal electrical activity (evidenced by a brainwave recording known as an electroencephalogram, or EEG).

  Brain Tumors and Hallucinations

  In 1995, neurologist C. M. Filley and colleagues reported on eight patients with brain tumors who had originally started with psychiatric symptoms. Running them down quickly:

  • Patient I had progressive apathy, social withdrawal, and poor selfcare.

  • Patient 2 was apathetic and irritable and had paralysis of half of the body.

  • Patient 3 suffered profound depression and ultimately developed a paralysis.

  • Patient 4 had two months of auditory hallucinations (content not described) followed by memory and word-finding problems.

  • Patient 5 was admitted with auditory and visual hallucinations and when examined, showed weakness of'one side of the body.

  • Patient 6 had disorganized thinking and flight of ideas and became manic.

  • Patient 7 noted episodic fear along with numbness of the legs.

  • Patient 8 had memory failure and apathy.

  The authors' point was that psychiatric symptoms can sometimes be the first clue that brain tumors are present. Most mental illness, however, is not associated with brain disease (only 3 percent of institutionalized psychiatric patients are found to have intracranial tumors).

  Mental Illness and Hallucinations

  When mental illness is present, hallucinations are quite common. Any of the five senses can be involved (people hallucinate the feeling of insects crawling on their bodies, of strange tastes and smells, as well as visions or sounds). For whatever reason, in psychiatric patients, the most common hallucination is auditory.

  Severe mental illness-psychosis-is generally divided into two primary types: disorders of thought processes (schizophrenia), and disorders of mood (depression, bipolar disorder, mania). Both are strongly hereditary. Sometimes they appear to overlap, hence the diagnostic term schizoaffective disorder (affect, as a noun, is doctorspeak for mood).

  Auditory hallucinations are classically associated with schizophrenia, and occur in 60 to 90 percent of the patients. Typically these fall into three categories: 1) audible voices that restate what the patient is thinking; 2) voices that give running commentary on what the patient is doing; and 3) two or more voices arguing, usually about the patient. Often, these are accompanied by delusions. Command hallucinations-advising someone to take a particular action -have been implicated in some highprofile bizarre murders (like Son of Sam), but, when studied, were not associated with a high risk of harm to the patient or others (unlike Son of Sam). The commands are usually ignored, but are more likely to be followed when the voice is familiar, or when associated with a delusion. Whatever the format, most schizophrenics believe their auditory hallucinations are coming from the outside. A sizeable minority of patients never realizes, despite treatment, that the voices aren't real.

  In a textbook example, "a 25-year-old schizophrenic farmer told of a talking tree on his property. During previous episodes he had experienced a variety of auditory hallucinations that were generally well controlled with medication. However, each time he came near this large old tree, he would hear a profound, wise voice-as if the tree were one with the earth and universe and had important guidance for him. He often came to the tree when he was troubled, seeking hallucinatory experiences."2 This is the substance of the kinds of myths and fables that can be found in all cultures.

  The Deaf Can Hear

  The perception of voices is so ingrained into schizophrenia that even the deaf hear them. Dr. M. du Feu, a psychiatrist to a unit for deaf' people in England, recently published a paper in a Scandinavian psychiatric journal in which sign language was used to interview schizophrenics who were born deaf. These patients, who had never heard a spoken word, were emphatic that they were hearing speech, rather than experiencing it in some other way. They described one or more voices, with content and format identical to that of the auditory hallucinations of the non-deaf. The authors make the point that the frequency and substance of schizophrenics' "voices" are about the same, deaf or not, and use words like "uncanny" and "inexplicable" to describe their findings.

  Of Schizophrenics, God, and Hallucinations

  Schizophrenia exists in all societies, and descriptions of its symptoms can be found throughout history. The illness afflicts just under 1 percent of the world's population, with roughly equal global distribution. Its cause is obscure, but it has something to do with over-activity of dopamine, one of the brain chemicals-known as neurotransmitters-that transmit nerve impulses. Drugs that block the activity of dopamine are helpful in this disease. Some feel that schizophrenics' brains are overwired with dopamine connections, creating paths to abnormal perceptions. People who suffer from episodes of acute schizophrenia often describe an enhancement of sensory perception. Normal people can at times experience this as well, either spontaneously, with drugs like LSD, or within religious rituals.

  In a 1981 paper titled "Mystical Experience and Schizophrenia," psychiatrist Peter Buckley compared mystical experiences of non-psychotics with those of acute schizophrenia. First-person accounts are remarkably similar: heightening of perception and thinking, a sense of transport beyond the self, a slowing of time, and a feeling of communion with God. These sensations were common to both, conveying the idea that both states were enabled by enhanced reception to normal stimuli. Hallucinations occurred in both groups, but tended to be visual in the mystical group, and auditory among schizophrenics.

  Auditory hallucinations also occur in other types of mental illness, though much less frequently. About twenty percent of manic patients and ten percent of depressed patients have them. Comparisons have been made between psychiatric and non-psychiatric groups. In one study, non-patients who heard voices perceived them as predominantly positive, and not scary or upsetting, as they often are in mental illness. In another study, schizophrenic hallucinators were compared to those with tinnitus (a high-pitched annoying sound in the ear, usually indicative of some sort of auditory nerve malfunction). Tinnitus is not considered hallucinatory; it's a dysfunctional nerve firing away, creating noise. Tinnitus patients without psychiatric illness, if they hallucinated, heard music, while schizophrenics heard voices.

  Getting back to A. B.'s Warning Voices ...

  The voices heard by A. B. described at the beginning of this chapter did not conform to any patterns doctors had previously run across. The eight patients with brain tumors listed earlier had overt psychiatric illness, which A.B. did not. She did not exhibit abnormal behavior, inappropriate emotion, or memory loss. Moreover, her hallucinations themselves were unlike any reported type-they were specific, goal-directed, and knowledgeable. As Dr. Azuonye put it, "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 tumor), 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."

  Twelve years after her surgery, A. B. phoned Dr. Azuonye at Christmas time to wish him a happy holiday and to let him know she had done well (no voices, no tumors, no illnesses). It was then that he decided to write up the case. He wound up presenting her (in person) at a medical conference, where she was questioned about her experience. The audience could not come to any conclusion about the origin of her voices
.

  Some believed this to be a clear instance of telepathic communication emanating from two well-meaning people who psychically found her tumor and sought to help her.

  Others theorized that A. B.'s tumor was perhaps diagnosed in her original country and that she came to Britain for free treatment under the National Health Service. But she had lived in Britain for fifteen years at the time and already was entitled to treatment, and she had also been so relieved when the voices first disappeared on medication that she celebrated with a vacation.

  Another group at the conference postulated that the tumor must have caused some subtle symptoms, perhaps creating enough fear that something was wrong that she hallucinated voices reiterating this. Possibly she had unconsciously taken in information about the Children's Hospital and the CAT-scanning facility and only thought she had never heard of them. Maybe the voices expressing satisfaction, post-operatively, reflected her own mind's relief.

  There was no conclusive evidence to support any of these theories. Suffice it to say that with unexplained phenomena, all bets may be considered "on."

  Why can normal people and schizophrenics share certain experiences? How come some mentally ill, even with treatment, never come to realize that they're only hallucinating? And how did A. B.'s voices know, better than her physician, exactly what was wrong with her?

  We will eventually understand all this, scientifically, and then it will be no more mysterious than invisible germs causing disease. Until then, all we know is that what happened to A. B. really did happen - Dr. Azounye, A. B., and the Britt,+h Medical Journal didn't make it up-and there has to be an explanation for it.

  SAX

  Animal House: Lycanthropy, or the

  Delusion of Being an Animal

  When I graduated from medical school in 1970, homosexuality was considered a disease. Psychiatrists classified it as a personality disorder: an aberration. Treatments were administered to try to cure those so afflicted, and these therapies were famously unsuccessful. Then, in 1973, the American Psychiatric Association removed homosexuality from their I)iagrwetlc ,I/Id Statmdtie•al .llaarral (I)S1!I, their all-inclusive almanac of mental illness). Being gay was no longer psychiatrically abnormal.

  As a young man, and throughout my training into the early '70s, it seemed like I didn't know anyone who was gay. Homosexuality was concealed then, and apparently it could be concealed reasonably well. I-low things have changed. I have a gay nephew. The vice-president has a gay daughter. Such knowledge was unheard of throughout half my life.

  Identity Crises

  Still included in the registry of psychiatric conditions is something known as gender identity disorder, which is considered distinct from homosexuality. This is a person's strong sense, usually from childhood, that they are "trapped" in a physical body of the wrong sex, a sort of disassociation between body and soul. Some of these folks will ultimately undergo sexchange surgery (known as gender reassignment) and/or take hormones to morph their bodies in the direction of their feelings. Katherine K. Wilson, a psychologist at the Gender Identity Center of Colorado in Denver, believes that psychiatrists' only concern with gender identity disorder should be in addressing the needs of those desiring sex reassignment by medical or surgical means, and that its current classification as an abnormality provides only stigma.

  Gender identity mismatch is much less common than homosexuality itself. In other words, gays experience same-sex attraction without necessarily feeling that nature gave them the wrong body. Reported cases of identity disorder find that men are affected three times as often as women. One study of boys with gender identity disorder in childhood found that the majority (in fact, two thirds: 30 of 44) became bisexually or homosexually oriented as adults. It remains to be seen if this stays classified as a psychiatric disorder, or evolves, as homosexuality did, into a mere variation of the human condition.

  This chapter is about what might be called species identity disorder. Harvard Medical School psychiatrist Aaron Kulick and colleagues published, in 1990, a case report of a man who truly believed himself to be a cat. Officially, this is called lycanthropy: the delusion of being an animal. The name derives from the Greek myth of Lycaon, whom Zeus transformed into a wolf. Like homosexuality, it can be found in all cultures and throughout history, although it's decidedly less common. Kulick believes that lycanthropy is more frequent than previously thought.

  The Man Who Would Be a Cat

  Kulick's patient was an unmarried twenty-six-year-old man, employed full-time, who was being treated for severe depression. This problem stretched back to his freshman year at college, and included alcohol abuse, poor concentration, and disorientation. During the supervening years, a milder depression continued with intermittent severe exacerbations. f3v the time Kulick saw him, he couldn't cat or sleep, had no energy or motivation, was tearful, and had recently attempted suicide.

  At their first meeting, the young man mentioned-by the way-that he had suspected since his childhood that he was, in fact, a cat. His youth did not sound particularly happy. He had a depressed, often bedridden, mother, and had spent many hours tied to a tree along with the family dog, whose behavior he would emulate. At age eleven, he formed some sort of relationship with the family's feline pet, and learned to "speak cat," conversing with mewing and feline gesturing. He began hanging out and hunting with the neighborhood cats, eating small prey and raw meat.

  He frequently visited tigers at zoos, and coin inunicated with them. By age seventeen, he concluded that he was some sort of' tiger. More recently, he had fallen in love with a female zoo tiger, and was distraught when the animal was sold to it zoo in Asia. This event precipitated the suicide attempt.

  Yet throughout his life, he had friends. In high school, he was elected class president, and was editor of the school newspaper and yearbook. He had several extended sexual relationships with women (although he preferred the company of cats). When hospitalized, friends and colleagues visited frequently, and his interactions with them were deemed socially appropriate by hospital personnel.

  But beneath it all, he considered himself a tiger with a deformed body. He outfitted himself in tiger-striped clothing, and felt more comfortable when so attired. He sported sideburns, moustache, and beard, all bushy but well groomed, and kept his nails long; he maintained a rather feline appearance.

  He had enough connection to the reality of contemporary American society to conceal his "true" identity. At seventeen, he did confide in a few close friends and psychiatrists. He often required formal psychiatric care, due to depression and perhaps to the stresses of living what he saw as a lie. There was mental illness in his family: a grandfather and cousin had committed suicide; two aunts had died in psychiatric institutions. He himself had required four psychiatric hospitalizations beginning at age nineteen, three of which were at Kulick's facility.

  During these breakdowns, he sometimes hallucinated a tiger companion; at other times he became non-functional and growled and crouched in feline positions, sometimes for several days. In lighter moments, he bemoaned his physical, non-cat body but maintained his fundamental obsession. Otherwise, thought processes and perceptions were usually intact.

  And he received treatment. Lots of it. Smorgasboards of antidepressants, tranquilizers, and mood stabilizers. Electroconvulsive shock therapy. Psychotherapy. While these alleviated the depression, they never took away the central theme of his life, that he had been born a cat. At the time the paper appeared in The,luurual o/'Nerrnu,faad eflerrtal I)t:seaee, he was on several medications, sharing an apartment with two friends, and working and functioning well. What impressed Kulick was the stubborn resistance of his patient's basic delusion to treatment.

  More Cases

  Kulick's colleague, Paul Keck, had been the lead author of a 1998 study, "Lycanthropy: Alive and Well in the 20th Century." Keck et al. collected, from memory, twelve cases from McLean Hospital in Boston over the previous twelve years of patients who claimed to be, or acted like, anima
ls. These were psychiatric inpatients, and their lycanthropic behavior generally occurred within the context of acute or chronic mental illness. Keck believed that the nature of these patients' psychiatric illnesses was no different from those of the hospital population as a whole. That is, no specific psychiatric syndrome could be expected to include, or exclude, lycanthropy.

  Five previously reported cases were reviewed in the paper: three were wolves, two were dogs. All had remitted (i.e., lost the animal alter ego) with therapy, which was predominantly drug treatment. Keck's twelve new cases included six who identified themselves as canines (wolves or dogs), two who believed they were cats, another a gerbil, yet another a bird, and two who did not embody a specific animal but exhibited feral behavior, like growling, crawling, hooting, or howling. Treatment accomplished remission in seven of' them, partial remission in three, and not much in two. In clinical parlance, those two would be known as refractory to treatment.

  As mentioned, there was nothing distinctive about these patients' psychiatric diagnoses (other than the lycanthropy). Overall prognosis did not seem to be related to animal identification syndromes. These patients were medically and neurologically unremarkable, meaning that neither physical examination nor laboratory studies turned up specific abnormalities.

  Kulick and his co-authors are struck by the fact that lycanthropy cases, although rare, can still be found, and that many such individuals may go undetected or undiagnosed. Co-workers and acquaintances of the "cat-man" may have found him a little odd, but likely had no idea what was really going on inside him.