Lilliputian Hallucinations and Marijuana Dependence in a Bipolar

Lilliputian Hallucinations and Marijuana
Dependence in a Bipolar Patient
Ma tth ew L. Bush 1 (MS IV) an d Saurabh Gupta M.D. 2
Abs tract
L illiputian hallucinations are rarely seen in manic pati ents. Here we present a case if
isolated lilliput ian hallucinations against a backdrop of psychosis and marijuana use. The
phenomenon is interesting and worth fol loioing Ul) with. The patient recovered and a brief
literature search is included.
INTROD UCTION
In 400 A.D. Sa int Macariu s, th e Egypti an , expe rience d and described a bizarre
perceptual ph en om en on (2) . Aft er a period of fas t ing, he visua lized "l itt le strangers"
whi ch he beli eved we re "dae mo ns like flies se tt ling on his mouth (2)." In 1726,
J on athan Swift coine d th e term " lilliput ia n" in hi s sa t ir ica l boo k, Gulliver's Travels. He
d escribed th e inhabit ant s of th e land of Lilli pu t by wri ting, "I fe lt something aliv e
movin g on my Leg, whi ch adva nc ing ge n t ly forward ove r my Breast, ca me almost up
to my C hin; whe n bending m ine Eyes down wa rd s as mu ch as I cou ld , I perceived it
to be a hum an C rea t ure not six In ch es high , wit h a Bow an d Arrow in his H a nds, a nd
a Quiver a t his back (3) ." In 1909, Le roy ut ilize d th e term "li lliput ian " in th e
descript ion of a spec ific type of pe rceptu al ab norma lity (4) .
Visu al hallucin ation s in which peopl e, a nima ls, or objects appear red uced in siz e
a re referred to as lilliputian hallucin ation s. H allucin ati on s of th is type have been
associa te d with variou s psychi atri c cond it ions (4,5, 12, 14, 15, 16), se nile dement ia (16),
neurologic di sord ers (8- 10, 17), toxi c met abolic sta tes (6,7), head trau ma ( 13), AIDS
( 13), and opht halmologic di sord ers ( I I). This ph en om en on ca n be pleasu ra ble (4) or
terrifyin g (2) depending on th e con te nt of th e hallu cination a nd t he contex t in whi ch
it is ex pe rie nce d .
CASE REPOR T
Mr. W is a 24 yea r-old Afro-Am eri can mal e wh o has bee n hospit a lized for
bip olar di sord er, type I, manic type on five diffe ren t occas ions . H e has a IO-yea r
I Matth ew L. Bush is a med ica l studcnt at J oa n Edwards School or Medicine and Ma rs hall
Un iversi tv.
2Sa ura bh 'G upta, ~d.D . , Psychi a t ris t, ~[M Ba tcm a n Hospita l and Assist ant Profes sor, Dcpt. o r
Psych iat ry, J oa n Edwards School or Med icine and Ma rs hall Univ crsitv, Huntington .
Gil
L1 LLlP UTI Ai''; HALL UCI NATI O i\iS
69
history of marijuana d ep end en ce. H e uses marijuana 4-5 tim es a week . How ever, th e
fr equ en cy of marijuana use escala te s during hi s manic e pisodes . H e de ni es us e of
ot he r illi cit drugs. H e has neve r di spl a yed a ny signs of psych osis wit h his mania or
dru g use . Th e pati ent lacks a hi st ory of head t raum a , ne u rol ogic impairm ent , a nd
me dical illn ess.
H e was a rres te d for possession of m arijuana . In th e two week s prior to his arrest ,
he was non compli ant with his m edi cation a nd he ex hibite d sig ns of hypoma nic
behavior and incr ea sed marijuan a use . While in prison he was expose d to ma rij ua na ,
possib ly mix ed with a hallucin ogen , a nd he began exh ibit ing bizarre beh avior suc h as
kissin g a nd r ubbing th e prison ce ll wa lls ina ppropriat ely and sm earing his feces
aro und th e cell and o n his clo t hes . Marijua na was t he only co nfirm ed substa nce used
by t he pa tien t wh ile in prison.
On ad miss ion, he exh ibi t ed agita t ion, aggress ion, rambling speech , fluctu ation
in consc io us ness, a nd confus ion. Th e pati ent exp ressed grandios e and paran oid
d elu sions. H e sta te d that he wa s "t he pr esid ent " a nd th at t he sta ff "was going to
shoo t him ." H e was sta r te d on ben zodiazapines as well as ant ipsychoti cs to co nt ro l
his ag ita ted sta te . During a n int erview on th e da y afte r admission, th e pati ent
ex pe rie nce d a visua l hallucin a tion. H e co un ted six "lit tl e people " in th e room. He
becam e ve ry paran oid a nd ag ita te d as he observed a nd described t his ha llucina tion.
Th e pati ent cla imed th a t th ese "lit tle peopl e" e ngaged in hu moro us as well as
th reat ening ac tiviti es . H e resp ond ed ve rba lly to th e ac tivi t ies of th e images. He was
un abl e to describe th ese "litt le men ." H e a lso claim ed that he saw a redhead ed man
who he th ou ght was th e devil.
Ph ysical exami na t ion of t he pa ti en t reveal ed no a bnormalit ies. His urin e drug
screen wa s positive for marijuan a . No evide nce of alcoho l or an y other drug use could
be found in th e lab work. Th ere were no d ru g chromatography tes ts or brain imagin g
st ud ies perform ed. Mental st atu s exa m ina t ion revealed a black ma n of average bui ld
a nd hei ght who was poorly groo me d . H e wa s orie n te d only to person a nd place . Hi s
eye con tac t wa s poor and he rapidly shifte d hi s gaze a ro u nd th e room. Hi s psych omotor ac t ivity involved aggress ive sha king of hi s a r ms a nd hands, as if he we re e ngaging
with some t hing or som eo ne . Hi s mood was agit a ted and he displayed a la bile affect.
He was a ble to compre he nd spe ec h, but he res ponded a t a slow rat e a nd he wa s
inappropriat e a t tim es. Hi s st ream of th ou gh t exhibite d tangen tia lity, as his a t te ntion wa s div ert ed from a nswe ring objective qu esti on s to int e ractin g wit h hi s visual
hallu cination s. The pati ent 's th ought con te n t reveal ed lilliputi an hallu cin at ion s. He
sta te d, "T he re a re six littl e peopl e in this room ... peopl e a ro und me a re being
ha rm ed .. . . I se e a red head ed d evil m an. " Obse rvi ng th e ac t ivit ies of th e "litt le
peopl e" ca use d him to lau gh a t ti mes, but he a lso respond ed to aggressive acts by
ye lling, "S to p hurt ing her!" H e was un abl e to comme nt on th e size of th e little people
or t he d et ail s of th eir a ppea ra nce . T he pa tien t deni ed a udi to ry, olfa ctory, gus tatory,
a nd tactil e co m pone n ts to thi s hallucin ation. Th e pati ent rep ort ed delus ions of
g ra ndios ity, in whi ch he stat ed th at he was "ge t t ing ca lls from Kuwa it a nd Ira n
co nce r ning a secre t m eeting. " H e rep ort ed no su icida l or hom icid al ideati ons. He
refu sed to particip at e in cog nit ive testing.
70
J EFFERSON J O URl"lAL OF PSYCHI AT RY
The pati ent wa s give n a 5 mg dose of Haldol to ca lm hi s agit ation . Rep ea t
laboratory data reveal ed no a bno r mality in his C BC or elect rolytes . H e con tin ued to
report th ese hallu cin ation s for a few days; a lt ho ug h , he d ispl ayed dis organized
thoughts, thought broadcasting, paran oid a nd gra ndiose d elu sions, biza rre beh a vior
a nd signs of ag gr ession for two mor e weeks . H e was m ainta ined on Hald ol 5 mg tid ,
C oge n tin 2m g bid , a nd Dep ak ote 500mg bid until his m anic behavior and psych oti c
sym pto ms subs id ed . At th e ti m e of di sch a rge hi s ment al status exa m revealed no
a bnormaliti es and h is cognit ive fu nct ion was fu lly in ta ct. H e wa s unable to recall his
lilliput ia n hallucinations. H e was d isch a rged to th e ca re of his fam ily, maintain ed on
his regu lar dose of Dep ak ot e, a nd wa s followed up by hi s commun ity m ent al hea lth
ce n te r.
DISC USSIO N
Lilliputian hallucin ations a re se ldom report ed in psychi atric literature and have
not been pr eviou sly record ed in a bipol ar pati ent. H endrickson described lilliput ia n
hallucination s in a chron ic sch izophre nic patient a nd sta ted t ha t "t ra d itiona l lor e in
psychi atry reinfor ces th e notion th at visua l hallu cin ation s are typ icall y of druginduced, m etabo lic or organic psych oses a nd unlik ely to occur in th e so-ca lled
'fu nc t iona l psych oses' lik e sch izoph re nia " ( 15).
This pati ent expe rie nce d a n acut e man ic episode; howeve r, he al so exh ibite d
signs of psych osis. Hi s psych osis involved primarily lilli puti an halluci na tions, in
whi ch he sa w "litt le peopl e " engaging in humorou s a nd th reat ening act ivit ies. Th is
could be described as Bip olar I di sorder, m anic type with psych oti c fea t ures. Th e
differential diagnoses includ e int oxi cation d elirium, subs ta nce-ind uced psych ot ic
di sord er, su bsta nce -ind uce d mood di sorder, bri ef psychotic e pisode, a nd schizophreniform di sorder. Seve ra l fact ors may hav e con t ribu ted to th e pa ti e nt's visual
psych op athology.
Subs ta nce int oxication may have been th e primary instigat or of t hese ha llu cination s. Lilliput ian hallucin a ti on s a re not typicall y associat ed wit h marijuana use;
however, th ey are not un com mon in hallucinogen intoxi cation . Takoa ka d escribed a
pat ient wh o expe rie nced lilliputi an hallucin ation s as a result of ch ronic ingestion of
psych oactive co m pone n ts of coug h syr up ( 14). Harper a tt ribut ed lilli pu tia n hallucination s to Amantidin e th e rap y in three of hi s pati ent s (6). T h is pa ti ent used
m a rijuan a on a regul ar ba sis but had never expe rie nced biza rr e percept ual cha nge s.
Whil e he was in prison he smoked som e marijuana th at wa s possibl y mi xed wit h a
hallucin ogen suc h as PCP or LSD . Th ese hallucin ogeni c drugs would not have sh own
up on a ro u tine urine dru g sc ree n but could leave res id ua l effec ts . D ru g ch ro ma tography st ud ies would have been helpful to d e te rm ine if th e pa tien t was expose d to a
hallucin ogen while in prison . This residu al drug int oxica tion could hav e led to his
sta te of psych oti c be hav ior a nd e nsuing halluci nation s. If th e pati ent wa s not expose d
to a hall ucinogen while in prison, he m ay have develop ed a marijuana-induced
psych ot ic disorder ind ep endent of his moo d diso rder. T ak oak a not ed th a t, "s ub sta nce-induced psych oti c di sord e rs ca n occ u r within 2 week s of substa nce usc" ( 14).
LILLIPUTIAN HALLUCINATIONS
71
These hallucinations and th e drug us e may be a result of th e pati en t's Bipola r
I di sord e r. At th e tim e of th e e pisode he wa s expe rie nc ing an ac ute manic episode.
Recent non compliance with his medi cation result ed in a rel apse of manic beh avior.
According to th e pati ent and his family, it is com mon for his mani a to result in
incr eased drug us e and impulsivity. This patient had never expe rie nce d, prior to t his
episode, an y psychotic symp toms. It is pos sibl e th at thi s pati ent is beginn ing to
d evelop psychotic symptoms as part of his Bipolar I di sord er, ind ep endent of h is
marijuana dep enden ce. The d egree to which th e pati ent's mood di sord er contribu ted
to this psychosis is ultimat ely unknown. Consequ ently, th e pati ent resp onded well to
m edi cation and th e hallucinations resolv ed as th e mania was m edi call y treat ed.
In st ead of attributing thi s e pisode to a singl e cause it see ms more likely th at t he
cu lp rit is a com bina t ion of th e a bove-me n t ioned factors. This case provid es usefu l
in sight into th e treatm ent of th e possibl e etiologies of lilliputian hallucin ation s. It
appears that th e psychosis in this pati ent is a byproduct of conc ur re nt mania and
marijuana intoxication. Th e successful treatm ent of thi s pati ent involved a n t ipsychot ics, mood-stabilizers, and benzodiazepin es. Thus, it is important to ca re fully
consider the interaction of psychotic, mood, and substance disord ers in es ta blishing
the etiology and th e treatm ent of lilliputian hallucinations.
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