Guided by voices
How did auditory hallucinations correctly diagnose a brain tumour?
A BMJ case-report, Diagnosis made by hallucinatory voices, has gone viral once again. It was originally published by Dr Ikechukwu Azuonye in 1997 and is sporadically covered by the media or discussed on social media.
It’s easy to see why it captures the imagination. The story goes that a woman develops voices in her head, telling her that she has a brain tumour…and they turn out to be right! The tumour is successfully removed and the voices go away.
The explanations I’ve seen so far have left me dissatisfied. It brings to mind another 90s classic, the X-Files, about an FBI unit for unsolved cases of paranormal activity. Like an agent from the X-Files, I’d like to reopen the case of Patient AB.
Patient AB
The woman in question, who Dr Azuonye refers to as AB, was a Swiss national who had been living in the UK for around 15 years. She was married with children and was in her mid-40s. She had no history of mental illness and was generally healthy - she rarely had to interact with the healthcare system.
One day, while reading a book, she heard a male voice inside her head which told her that he and a friend used to work at Great Ormond Street Children’s Hospital and wanted to help her. Dr Azuonye writes:
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.
In later interviews, he gave examples such as the voice correctly predicting which cars she would see driving past her home. Dr Azuonye diagnosed her with ‘functional hallucinatory psychosis’. The word functional here means he did not expect it was secondary to another cause (like a brain tumour). He prescribed her an old-school antipsychotic, thioridazine, and the voices remitted within two weeks.
To celebrate, AB went on holiday to Zurich. While there, the voices returned, telling her to go back to England for immediate treatment. Dr Azuonye mentions at this point she was also experiencing ‘beliefs of a delusional nature’ without further elaboration. Back home, the voices tell her to go to a particular address, and her husband offers to take her:
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.
Dr Azuonye finds no indications to suggest a brain tumour but requests a CT brain scan to reassure her. Initially the request was rejected but was later accepted ‘as a favour’ to him.
The scan picked up a tumour, a ‘left posterior frontal parafalcine mass, which extended through the falx to the right side’, consistent with a meningioma. These are considered benign, slow-growing tumours but can cause serious problems, such as seizures, personality changes, and cognitive problems, due to the compression of underlying brain tissue.
The neurosurgeon agreed there was no symptoms or neurological signs relating to the tumour and weighed-up whether to operate or continue to monitor AB. The surgeon, patient, and her voices all agreed that the tumour should be removed. The procedure was successful, here are the operating notes:
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.
When AB recovered from the operation, the voices spoke to her a final time, ‘We are pleased to have helped you. Goodbye.’ Antipsychotic medication was stopped soon after; there were no further hallucinations or delusions.
Explanations
This is certainly a remarkable case and several explanations have been put forward, both in the original paper and subsequent discussions. Dr Azuonye does not reveal his personal views in the case-report but gives three broad explanations from discussions with psychiatrists at a case conference.
The first is from psychiatrists he calls X-philes: ‘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 second, from X-phobes, suspect that AB was feigning her symptoms to get free NHS treatment. A third explanation is that the tumour was producing psychotic symptoms despite being otherwise asymptomatic.
Let’s leave the telepathic communication for now and assess the plausibility of the more mundane theories.
Feigning hallucinations
Could AB have been pretending to experience auditory hallucinations in order to access NHS treatment for a condition that had already been diagnosed? This explanation doesn’t work for me. Firstly, as Dr Azuonye points out, she was already eligible for free treatment in the UK having lived there for many years. Secondly, if this was her motive, why not feign more classic symptoms of a brain tumour - headaches, nausea, memory difficulties - rather than a rather outlandish scenario of voices telling her the diagnosis? It was luck that Dr Azuonye and radiology team, decided that a CT of her brain would be reassuring. Remember that the scan request was initially rejected! While not impossible, given the information available, I consider this explanation very unlikely.
Tumour causing hallucinations
Any intracranial lesion can result in psychiatric symptoms. Rarely, this can be in the absence of neurological symptoms. Symptoms are more commonly depression, anxiety, or personality change. One review estimated that 1/5 of patients with brain tumours had psychotic symptoms, however, in most they would have other more typical neurological symptoms as well.
There are reports same type of tumour, a meningioma, causing psychotic symptoms. In an analysis of 72 patients with meningioma, two patients presented with psychotic depression, in the absence of other neurological findings.
In another BMJ case-report, a 51-year-old woman who was diagnosed with a frontal meningioma after loss of consciousness, actually experienced psychotic symptoms (and was labelled with schizophrenia), ten years earlier. Whether these psychotic symptoms were caused by the tumour is difficult to know for sure, but is supported by the resolution of her psychosis after the tumour was resected. In this case, the psychotic symptoms seemed to have been caused long before the slow-growing tumour expanded enough to increase intracranial pressure.
In clinical practice today, sudden onset auditory hallucinations in an otherwise well 40 year old woman, with no past history of mental illness may well warrant brain imaging - whether the voices tell you to or not!
So it is plausible that the AB’s auditory hallucinations were caused by the tumour and its removal led to the remission of these symptoms. More puzzling is that the voices themselves seemed to predict events, including the diagnosis of the meningioma.
Coincidence?
Another explanation, suggested by @jphilipp, is pure coincidence. We know that psychotic disorders themselves are relatively common, with a lifetime prevalence of 1.5-3.5%. Experiencing any psychotic symptom (which you know is not the exactly as a psychotic disorder) is even more common, with an estimated lifetime prevalence of 7.8%. For psychosis to present in midlife in females, is not uncommon, in fact this has been argued to represent a time of increased risk.
Meningiomas are relatively common too, and occur in women more than men. In post-mortem studies, the rate of undiagnosed meningioma at death was up to 2.8% of women. The incidence of these tumours steadily increases from the age of 40.
So psychotic symptoms could have occurred randomly in AB and coincidentally she had an underlying meningioma. This co-occurrence will inevitably happen to someone, sometime. But what of the content of the voices? Anecdotally, I have met many people with psychosis who believed they have had a device, implanted into their brain. This usually forms part of a wider set of delusional beliefs. In some cases, a brain scan has been arranged in an attempt to reassure the patient. At some point, one of these brain scans done for ‘reassurance’ will pick up a tumour incidentally. You just never hear of the majority of scans that are done for reassurance that come back normal.
It is possible that these psychotic symptoms occurred randomly in AB. It is possible that the content of these symptoms were voices that told her she had a brain tumour. It is possible that AB coincidentally had a slow-growing incidental meningioma. Maybe the parts that the voices predicted other things and led her to the radiology department is stretching your ability to dismiss this all as coincidence though.
So what is going on here?!
Mulder and Scully
The unique selling point of the X-Files is the relationship between Mulder and Scully. A perfect team but diametrically opposed in crucial ways. Mulder is a maverick. He believes in conspiracy theories. He believes in aliens. He believes in UFOs. He has the below poster on his office wall.
By contrast, Dana Scully is a hard-nosed skeptic. She is a medical doctor and is full of doubt. The X-Files works because eventually even Scully becomes convinced. Conspiracies are real, aliens are here, Mulder was right all along! Eventually, Scully’s rigid skepticism gives way and she becomes a true believer like Mulder.
We give AB’s report high credence because Dr Azuonye is a respected Consultant Psychiatrist. Like most in his position, we see him a rational, scientific, and objective. He doesn’t even give his own opinion in the case-report, he merely reports that other psychiatrists suggested it may have been telepathy.
However, the case of AB starts to make sense when you realise that Dr Azuonye is not Scully. He’s actually Fox Mulder.
An extraordinary psychiatrist
There are clues that Dr Azuonye is not an ordinary, run-of-the-mill psychiatrist. His profile on ResearchGate states, ‘Doing research into the origin of species and writing about mental health law and the paranormal nature of psychiatry.’ Fair enough, you might think. He witnessed an unexplained clinical case, a brain tumour diagnosed by voices - would that not make you interested in the paranormal?
This wasn’t the first ‘miracle’ that he bore witness to though. In 1969, he was a Biafran commander in the Nigerian civil war. During an ambush of Nigerian troops, he noticed a sniper close-by, who shot at Dr Azuonye. Bullets struck close to his heart:
So great was the impact that I was knocked over. I just noted the small fire burning on my shirt as I realised that I had been killed in battle. I felt a profound sense of peace but nothing else. Then I heard the staff sergeant shouting to the men, ‘Let's remove the body before the vandals get here and chop it to pieces.’ The Biafrans always referred to the Nigerian troops as ‘vandals.’
As my men began to drag me through the undergrowth so great was the pain in the left half of my chest that I asked them to stop. There was utter consternation as the men, who had just seen me killed by the sniper, heard me speak—and even more so when we all saw a pile of bullets, still sparking flames. I had been hit over the heart by a burst of some 20 incendiary bullets and though they had set fire to my shirt and caused a huge haematoma not one of them had pierced my skin. Though I was glad to be alive, I was totally confused and it was only the pain that helped me to focus my mind on what was going on. By this time, the Nigerian survivors of my attack had begun to counterattack. My mortar command joined in to contain the counterattack.
For the rest of the war, troops would go into battle gathered round Dr Azuonye, reasoning that anyone close to him would not be injured. He recounts this story, in the BMJ, aptly titled, A Miracle Remembered and concludes, ‘All I can think is that I was somehow protected by forces beyond anything I understand, for which I am grateful’.
Dr Azuonye’s explanation
In the case-report, he did not offer a personal opinion but he does so in subsequent interviews. Here is a 2006 interview with the Daily Mail:
‘It is a miracle,’ says Dr Azuonye. ‘The patient regards herself as being helped by a guardian angel.’
Dr Azuonye was contacted by numerous other psychiatrists who had treated patients with similar experiences. These doctors feared for their careers if they went public with cases which defied conventional medical explanation. ‘Can you imagine what would happen if they told their clinical team a patient had been possessed by demons?’ says Dr Azuonye. ‘They’d be laughed out of court.’
He goes further with Jon Ronson in a 2011 Radio 4 series about voices. This is no longer available on the BBC website but you can easily find a clip on Youtube. I’m directly quoting his words below:
The most interesting was to hear fellow psychiatrists saying, ‘This must have been a paranormal experience. They were real individuals who had a way to help her, and they did.’
I personally believe that she was helped by someone. In my view, this world that we are experiencing is one of many worlds and I have no difficulty accepting the reality of non-physical worlds and its inhabitants. I think she was helped in that manner.
Now you know more about his beliefs, let’s go back through the case-report with the eyes of Dana Scully.
Questioning the case-report
With my skeptical hat on, there are a number of questionable aspects to the report. None alone is a smoking gun but each might plant a seed of doubt in your mind.
Publication 13 years after the event. If Dr Azuonye thought this case to be so important, why did he not publish contemporaneously? He explains that a Christmas phone-call from the patient brought it back to his mind. If you are a clinician, how accurately do you remember patients from decades earlier? You may know the gist, of the case, but you might also misremember certain aspects. Publication in 1997 is a major red flag for me.
Single author. Where are the neurosurgeon and the radiologist? Their input would give weight to the report. Where are the CT images, showing the meningioma? This may be a result of publishing the report so long after the diagnosis that these people were not contactable, but their absence is notable.
Describing the scan. In the case-report, a second CT head with contrast (a type of radiological dye), is needed to make the diagnosis. Presumably the first scan was inconclusive so a follow-up scan arranged at a later date. However, recounting to Jon Ronson, Dr Azuonye tells us that during the scan, everyone was so surprised at the finding that they called Dr Azuonye to view the images while the patient was still in the scanner. To me, this sounds highly unusual and at odds with how the scan was described in the report.
Lack of information about the delusions. Dr Azuonye reports that AB had delusional beliefs but does not describe these beliefs at all. Did she have systematised delusions involving the tumour inside her skull? This would increase the likelihood of her experiencing a psychotic disorder coincidentally.
Minor contradictions in interviews. In the Daily Mail, it is reported that the voices told the patient to go the Royal Free Hospital, in the Jon Ronson interview it is the National Hospital for Neurology and Neurosurgery at Queens Square, in the case-report it is ‘large London Hospital’. These details are irrelevant to the clinical findings but prove that details of famous cases can be misreported or change over time.
Lack of follow-up. We don’t really know whether AB’s symptoms completely resolved, apart from a single Christmas phone-call. If she were to have further psychotic relapses, this would be evidence against the tumour having a causative role in these symptoms.
Extraordinary claims require extraordinary evidence
I am not asking you to disbelieve the case-report. I am not suggesting it is likely for authors to embellish or exaggerate details. I am not casting aspersions about Dr Azuonye’s character.
I want you to consider though, what is the more likely explanation. That this case is a mixture of coincidences and inaccuracies, or that a woman’s brain tumour was diagnosed telepathically, perhaps by entities living in another dimension.
Is it more likely that Dr Azuonye experienced two genuine miracles in his lifetime, or that he is the type of person prone to explaining unusual phenomenon with paranormal explanation?
The truth is out there.
You be the judge.
An interesting tale, well told. Thanks
I am also sceptical of it ever happend that way!