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Revisiting the Charles Bonnet Syndrome in visually impaired students in Addis Ababa University, Ethiopia.


Many people who lose their sight start seeing things which are physically not there. They are normally aware that their 'visions' are not real, even if the images are vivid. This phenomenon named as Charles Bonnet Syndrome (CBS) in 1936 by Georges de Morsier, a neurologist after the name of a Swiss philosopher, naturalist, biologist and writer Charles Bonnet who wrote about his elderly grandfather's experiences of phantom vision in 1796. His grandfather, 89 years old Charles Lullin's vision was falling for some years, otherwise having reasonable physical and mental health. He began having "visions" after he lost his sight to cataracts. He could see patterns, people, birds, buildings etc. which were not really there. Lullin was fully aware about it. He recognized that these 'visual hallucinations' were secondary to his eye disease and distinct from those caused by mental illness.

The visual hallucinations of CBS have been compared to phantom-limb phenomenon which is known to be experienced by individuals whose body part(s) have been amputated. Phantom-limb syndrome is characterised by experience of sensations, pain and discomfort at the site of the amputated body parts. There are similarities between phantomlimb phenomena and CBS. In both the conditions there is loss of sensory organs but individual is having sensory experiences from these "so called organs" which does not exist in reality.

Hallucinations get less frequent with time. Initially it was thought that hallucinations resolved within 12 to 18 months, but most reported occasional hallucinations even after five years they first reported. However, any one of any age, including children, may develop this condition, as sight loss can trigger CBS. It can affect people at any age, but usually develops after losing sight later in life and also if vision is suddenly lost. But there several reports which tells that people who lost eye sight at younger age and deterioration of vision was gradual also experience phantom vision.

Epidemiology: Estimate of CBS varies, but it is thought that one in two people with visual loss may experience CBS. Other reports that 10-15 % of patients with moderate loss (Terao & Collinson, 2000) and possibly 30% of people with severe visual loss (Russell, 2010) experience CBS. It is thought that there are more than 100,000 cases of CBS in the U.K. Some researchers say that up to 60% of people who are experiencing serious sight loss may develop it.

Kind of things people see in their phantom vision: Most of the hallucinations may fit alongside the background one is looking at, like seeing cows in the field or fit with the past experience one has undergone. Sometimes these "visions" appears to be totally unrelated like seeing dragons etc. may be due to their phantasizing and imaginations. The hallucinations can involve detailed images of people, places, buildings or simple patterns of straight lines, brick work, mosaic or tiles, landscapes or group of people. There is some consistency among people in the types of images they see, most notably images of faces, children and wild animals.

Types of false vision / hallucinations may be simple or complex, sometimes appear out of blue or may be same every time, repetitive or different every time. They may be in black or white or in colours. They may involve movements or they may be static. They may be pleasant or disturbing, even frightening. It may be for seconds only or for a very prolong time. They may be realistic or fantasies (mythological figures or monsters).They may be controllable or not so.

Diagnosis: CBS is caused by sight loss only and not due to any other health problems. To differentiate hallucinations caused by other conditions in CBS, it is to make certain that they are visual only and not of hearing, smell or related to any other sense organ. It is also better to rule out other causes of hallucinations, like mental health problems,

Alzheimer's, Parkinson's disease and other conditions. Due to old age and diabetes, damage to optic pathways may occur. If it is bilateral or due to macular degeneration or due to toxic damage also some people are predisposed to CBS. Some simple tips to keep in mind for diagnosis of CBS are:

* Person has loss of vision

* Person reports / reveals seeing complex, persistent, repetitive hallucinations.

* Usually s/he has no control over it.

* Person is aware that these "visuals" are not real.

* Person does not have signs of dementia or mental illness.

Many researchers on CBS have written the term" Visual Hallucination". In a strict sense this term can only be used when persons were not having insight about their 'phantom visions', but it appears that in common practice of writing/reporting the term hallucinations have been interchangeably used for visual images which were phantom or false but experienced by blinds as real and crisp having full insight about it.

Research carried out by the present Author: A small piece of research was carried out by the present author to revisit the CBS. Quite a good number of visually impaired students, both boys and girls are taking higher education in different courses at undergraduate and post graduate level at Addis Ababa University, Ethiopia. There is good to reasonable support and facilities available for them here. They are usually seen moving here and there in the main campus of the university and appears to be well adjusted with the surroundings and environment of the university. Therefore, it was thought to have firsthand information about presence or absence of CBS in them.


Subjects: There were 10 visually impaired / blind students who were available and given their consent for the present research. As the first semester was near ending and examinations were going on as well as English speaking blind students were few in numbers, only limited numbers of subjects could be taken in this preliminary research. It was a snowball purposive/incidental sample. Out of 10 subjects two were girls and eight were boys/adult man. Eight subjects were between the age range of 21-28 years and two men were of 38 and 43 years of age. Seven of them were pursuing different undergraduate courses, two were in Master's program and one was doing his Ph.D.

Procedure: First the ethical clearance from the department was taken for the research. Then available visually impaired person was personally approached and investigator enters into a conversation with him / her. At this point it became clear whether s/he can converse in English language? If so request was made to him to spare some time for this research which was explained to him. Either they came immediately or fixed an appointment. Each person was individually interviewed. An in depth clinical interview was carried out with the help of a schedule which was prepared for this research. Responses were noted down. At the end of interview we indulged into a debriefing conversation and the person was also requested to send or bring another blind colleague. In this way 10 interviews were conducted within a month time. All of the subjects co-operated very well and were indeed happy to do so. In analysis frequency and description was taken into consideration.


Results / information obtained from individual in depth interviews guided by a pre prepared schedule has been briefly mentioned in the above tables, however. It needs elaboration. All of the 10 subjects became totally blind after some time of the first occurrence of damage to their eyes. Gradual diminishing of their sight as mentioned in the table was matter of a few days or months only. It appears that 4 of them lost their sight due to some disease / brain disease, 2 due to accidents and 4 due to reflection of or exposure to sun rays. Some of them mentioned that their parents believed that the loss of vision in them was due to devil, black magic or evil spirits. They have been taken to some hospitals, but doctors said that it was too late or irreversible. All of them can sense light, shadow also but cannot see things. Two girls and others who lost their vision in early childhood have not reported having CBS as there was not much in memory store to be replaced by phantom vision. Many of them have visions of their parents, face of their mother, friends, relatives, religious cultural and festival ceremonies, animals, trees and surroundings where they have spent their childhood. Some reported as if they are really seeing them vividly and some said it was due to their imagination about past. But all of them said that it was not real. With most of them these vision last longer, but a few reported it lasts only for a few minutes. One person reported that these images were with him when he was giving interview. Another person reported that as he becoming older and older these images and their colours are losing their shines and they are becoming dim and dim. Other person have reported that he don't see the images when he is awake but he was getting them in dreams which are very scary and frightening. He used to get nightmares which disturb him a lot.

Most of them see these images when they are lonely at bed time or in the evening, but when they are busy they don't experience them. For most of them seeing these images is a pleasant experience with a mix feeling that now they are missing them. Some of them have mild depression or anxiety, but try to overcome on these by looking forward, having hope for the future, engaging themselves in higher education, listening to radio and having a social life and friends. Most of them have accepted their blindness as reality in a rational way and to a great extent in emotional way also, but one person said that he is not so much troubled by his blindness but by his poverty. One person was greatly disturbed by his phantom visions and wish if he may get rid from these.


Causative explanations of CBS: Phantom vision seems to appear in blinds when nothing much is going on at the time in their life or daily life, like sitting alone, quite or when they are lying in bed at night. The main cause of CBS is loss of vision and how Visually Impaired Person's (VIP's) brain reacts to this loss. Visual inputs from the eyes stop, so it allows the brain to replay with its stored visual library.

Current researches also suggest that when someone has lost his / her sight, s/he is not receiving as much inputs from his / her eyes as it used to be. So his/her brain sometimes fill in this vacuum by fantasizing or releasing old visuals that it has stored. Thus CBS refers to phantom visions caused by the brain's adjustment to significant vision loss.

It has also been suggested that decreased or absent stimulation of eyes leads to increased excitability of the visual cortex (deafferentation hypothesis), which in turn release visuals. It is massive cortical reorganization after the sensory loss. This hypothesis gives the best available patho-physiological account. Although it fails to explain the absence of hallucinations in the majority of patients with eye disease. (Ffytche Dominic, 2009) This release phenomenon is compared to phantom limb symptoms after amputation.

There are also reports of inducing CBS under experimental conditions (Jackson & Ferencz, 2009, Merabet, Maguire,Worde and others, 2004) and in therapeutic eye patching (Khadavi, Lew & Goldberg,2010).

Creating Community Awareness: Most people are not aware of this condition and they suffer from CBS silently. They do not talk about it with others and do not consult with their doctor even if such facility is available, out of fear and embarrassment, as they think that such symptoms (hallucinations) will be associated with mental illness. They are aware that these visual images are not real but they may remain worry that it may be an early sign of some mental sickness.

Although there is no cure or treatment of CBS, but simply being aware that their symptoms and phantom visions are not result of mental illness can help them to manage their life more happily.

Following tips though very simple can help them to a great extent:

* Awareness and understanding of CBS

* Switch a light if so called hallucinations appear in the dark

* Engaging eyes for some simple exercises like - moving eyes left to right, blinking the eyes for some times, moving them around.

* Keeping oneself busy in some activities and changing the routine if it helps

* Get relaxed and learn some relaxation techniques

* Consult your doctor and get the help of some friends to visit the helpful websites.


Damas J. Mora M. Skelton-Robinson and F.A. Janner (1982) The Charles Bonnet Syndrome in Perspective. Psychological Medicine,12,251-261.

Ffytche, Dominic H. (2009) Visual hallucinations in eye disease. Current Opinion in Neurology, 22(1)28-35.

Jackson M.L., Ferencz J.(2009) Charles Bonnet Syndrome: Visual loss and hallucination. CMAJ, Aug 4,181(3-4):175-6.

Khadavi N.M., Lew H, Goldberg R.A. & others (2010) A case of acute reversible Charles Bonnet Syndrome following postsurgical Opthal Plast Reconstr Surg. CMAJ, Jul-Aug,26(4) 302-4.

Menon G., Rahman I., Menon S., and Dutton G. (2003) Complex visual hallucinations in the visually impaired: The Charles Bonnet Syndrome, abstract. Sury Ophthalmol 48(!0:58-72.

Merabet L B, Maguire D, Warde A and others (2004) Visual hallucinations during prolonged blind folding in sighted subjects. J Neuroopthal, 24:109-13 (Pub Med)

Terao T. & Collinson S. (2000) Charles Bonnet Syndrome & Dementia. Lancet, Jun 17:355(9221);21-68.

Ramchandran V S and Sandra Blakeslee (1988) Phantom in the brain. Harper Collins, Pp 85-87.

Russell G. (2010) Age related macular degeneration is associated with CBS. BMJ, March 24,340.

Schultz, G. and Melzack, R. (1991) The Charles Bonnet Syndrome 'Phantom visual images'. Perception, 20,809-825.

Sood S, Nada M, Nagpal R. C. (2004) Prevention of blindness and mobility of a blind. Ind J Community Med, 29(2) 92-95.

Y. S. Vagrecha, Professor (Clinical, Counselling and Health Psychology) School of Psychology, College of Education and Behavioural Studies, Addis Ababa University, Ethiopia

Other Information sources:

www.charles bonnet

CBS Fact Sheet, Vision Australia

Royal National Institute of Blind people

Royal College of Ophthalmologists

Received: August 16, 2015

Revised: December 12, 2015

Accepted: January 15, 2016
Table 1

Subject's   Sex   Marital     Educational    Current
Serial            Status      Status         Age (in
Number                                       years)

1            F    Unmarried   IInd year      21
                              Law student

2            F    Unmarried   B.A.           25

3            M    Living in   IInd year      21
                  relation    Law student

4            M    Living in   Final year     26
                  relation    Law student

5            M    Unmarried   IIIrd year     26

6            M    Unmarried   IVth year      23
                              Social Work
                              UG student

7            M    Married     III rd year    27
                              Pol. Sc. &
                              UG student

8            M    Living in   Ist year       28
                  Relation    M.A.
                  ship        Linguistics

9            M    Married     M.A. Ist yr.   38

10           M    Unmarried   PhD student,   43
                              (Peace &

Subject's   Vision        Cause of        Vision       Current
Serial      Impaired      Impairment      Impaired     Rt. / Lt.
Number      at the        of vision as    Suddenly /   Vision
            Age of        stated /        Gradual

1           1-2 Yrs.      Internal,       Gradual      00/00
            after birth   something
                          like cancer

2           10 Yrs.       Hen bite        Gradual      00/00
            after birth   infection

3           09 Yrs.       Parents are     Sudden       00/00
            after birth   not sure -
                          black magic

4           05 Yrs.       Reflection of   Sudden       00/00
            after birth   sun light on

5           14 Yrs.       Explosion of    Gradual      00/00
            after birth   bomb /

6           6-7 yrs.      shouted in      Sudden       00/00
            after birth   the night /

7           19 yrs.       Exposure to     Gradual      00/00
            after birth   Sun rays /

8           04 yrs.       Due to          Sudden       00/00
            after birth   reflection of
                          Sun rays

9           11 yrs.       Severe          Gradual      00/00
            after birth   Headache
                          Nerve T.B.

10          10 yrs.       Reflection of   Gradual      00/00
            after birth   Sunrays
                          / evil cause

Table 2a

S. No.      Appearance of         Images         Images
             some images        Appears to       Can be
             before them         Be Crisp      Controlled
                                  / real?        Or not?

1                 No               N.A.           N.A.

2                 No               N.A.           N.A.

3                Yes            Crisp/real       Cannot

4          No, I feel moon,     Real / very       N.A.
          insects around me    nice / bright

5                Yes               Real          Cannot

6                Yes               Real          Cannot

7                Yes               Real          Cannot

8                Yes               Real        Can control

9         Yes, but in dreams    Appeared to      Cannot
                                  be real        control

10               Yes               Real          Can not

S. No.        Duration        Whether      Insight
             of images         Images       About
             Shorter or       Changes     Unruliness
              Longer?        Their size   Of images
                                          Present /

1               N.A.            N.A.         N.A

2               N.A.            N.A.         N.A.

3              Longer           Yes        Present

4              Longer        Big shadow    Present

5         Shorter duration       No        Present

6         Longer duration     Changing     Present

7              Longer        No drastic    Present

8             Shorter        No change     Present

9              Longer         Changing     Present

10        Longer/momentary   No change     Present

Table 2b

S. No.     Emotional affects      Time of occurrence
          after seeing images         of images

1                 N.A                    N.A.

2                N.A.                    N.A.

3                Mixed              Evening/night

4              Pleasant              When lonely

5             Discomfort             When lonely

6             Troubling /         Any time, his time
              discomfort                 also

7            Uncomfortable      When lonely, not busy,
                                 thinking about past

8         Friendly, dog image    No time, when bored

9              Scarring         During night in dreams

10        Mixed, I miss them     When lonely, during
             so unpleasant              night

S. No.       Subject's          Accepted the        Any Psychiatric
            social life      condition or denial       symptoms?

1           Good / Many           Accepted                Nil

2              So-so              Accepted                Nil
           Some friends

3          Very social /          Accepted                Nil
            many friend

4           Very good /     Accepted / useful to          Nil
             excellent               me

5             Missing         Can compensate by     Mild depression
              mother           education only

6           Social, so      Accepted, but like to          No
           many friends      be free from these

7          Mixed, social     Accepted, doing for           No
                                better life,

8           5-6 friends       Dislike poorness,     Mild expression,
                            blindness rationally        anxiety

9             Missing         Accepted totally         Depressed,
          friends, family                               Anxiety

10             Mixed           Accepted, when              No
                                problem arise
                               complain to God
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Article Details
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Author:Vagrecha, Y.S.
Publication:Indian Journal of Community Psychology
Article Type:Report
Geographic Code:6ETHI
Date:Mar 1, 2016
Next Article:Personality, beliefs about medication and adherence to medication among chronically-ill patients.

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