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By Dr Raj Persaud FRCPsych Consultant Psychiatrist
BBC News is reporting that that the pilot of the Germanwings plane, which crashed killing 150 people on board, had seen seven separate doctors in the month before the crash - one GP, three psychologists and three eye specialists.
It has now emerged that co-pilot Andreas Lubitz, who is alleged to have flown his plane into the ground on purpose, was troubled about possible problems with his eyesight. BBC News reports that just over a week before the crash, he told one doctor he was only sleeping two hours a night, and feared he was going blind.
However it also now emerging doctors could find no "organic cause" for his failing sight, with one doctor reportedly suggesting that it might have been due to psychosis.
Is it possible to believe you are going blind or even lose your sight, but for this to be rooted in psychological causes, rather than a physical one?
What is referred to as 'medically unexplained visual loss' or non-organic visual loss (NOVL), is reported to occur in 1 to 5% of patients attending ophthalmology clinics. In many cases it continues without improvement for an extended period. It is reported that between 45% and 78% experience complete resolution of all visual symptoms, which also means that a substantial proportion can remain disabled.
While psychological causes are presumed in many such cases, the underlying neurological or psychological mechanisms frequently remain mysterious.
In some cases the visual loss is deliberately feigned for secondary financial gain, as in the case of a possible impending insurance pay out following an accident, or maybe there is a need to avoid military service.
Doctors spot the person feigning the illness, or 'malingering', using a variety of tests. For example, in some simple writing and finger pointing tasks, the genuinely blind perform differently to those pretending to have lost their sight.
Another possible cause is that the eye sight problems are a physical manifestation of underlying stress, or that some of these patients are particularly suggestible, meaning that worrying about losing their sight turns into a kind of self-fulfilling prophecy, through excess anxiety.
A study entitled 'Severe Psychogenic Visual Loss in a Girl with Siblings Blinded from Congenital Glaucoma', published in 2006, reports the case of a 10-year-old girl referred for treatment of presumed juvenile glaucoma.
This case study by Arif O. Khan, from the King Khaled Eye Specialist Hospital, Saudi Arabia, reports that her visual function was normal until 2 years prior to referral, when she suddenly claimed she could not see, preferring dark rooms. Four of her five siblings were physically blind from untreated congenital glaucoma.
However, when the patient was offered sweets she correctly identified their colour, while keeping her eyelids closed. When some lenses were dropped on the floor, she readily picked them up without difficulty.
The father explained that his blind children took most of both parents attention, with much less being given to his daughter. The medical advice was that his daughter's visual loss was psychological, and that the best treatment was parental attention, without directly confronting her, regarding the visual loss.
Six months after the ophthalmic consultation, the father related that more attention was being given to his daughter's needs, and that she no longer seemed to have difficulty with her vision.
This case study was published in the 'Journal of The American Association for Pediatric Ophthalmology'; this kind of case is referred to as 'functional visual loss' and illustrates how careful handling and wording during the consultation is essential.
In a high stakes situation, as when even small deviations in visual acuity can have catastrophic career consequences, such as being a pilot, it is possible that people with a background of anxiety or depression, get more worked up about their eyesight.
Stanley Thompson, an Ophthalmologist based at the University of Iowa, published a paper entitled 'Functional Visual Loss', in the 'American Journal of Ophthalmology', where he confirms that handling a case where the visual loss has no physical medical explanation, can be tricky.
He gets inside the mind of such a patient, and illustrates the mental processes involved in their conflicted relationship with doctors: "He is treating me. He wouldn't treat me without a good reason, therefore there must really be something wrong with my eyes. However, he said my eyes were OK. That means he must be hiding the real problem from me. I wonder what I have that is so awful that the doctor feels he has to keep it from me."
In a study entitled 'A Psychological Perspective of Eye Floaters', authors Sabrina Cipolletta, Alessandra Beccarello and Alessandro Galan, point out that a UK survey revealed that 14 patients per month per optometrist presented symptoms of 'floaters'.
These are spots, threads, or fragments of what appear to be cobwebs that float about in a person's field of vision and can cause a lot of psychological distress. The study, published in the academic journal, 'Qualitative Health Research', points out floaters are especially visible when looking up to gaze at the sky.
Frequently, they are experienced by patients, even if no objective pathology can be found in the eyes on examination by specialists. This predicament, in my experience as a practicing psychiatrist, can lead some doctors or optometrists to view the patient as psychologically disturbed, or perhaps even sometimes 'delusional'.
Whatever was the case with Andreas Lubitz, whatever personality, medical or psychological problem led to this enormous tragedy, despite the new information, we still don't know the diagnosis.
However, it is important to remember that studies suggest the majority of people with 'functional visual loss', eventually recover.
Early access to high quality psychiatric and psychological care is clearly imperative as a way of ensuring safety of all, rather than stigmatising psychological problems, as appears to have been the response in some sections of the mainstream and social media.
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Raj Persaud and Peter Bruggen are joint podcast editors for the Royal College of Psychiatrists and also now have a free app on iTunes and Google Play store entitled ‘Raj Persaud in conversation’, which includes a lot of free information on the latest research findings in mental health, psychology, psychiatry and neuroscience, plus interviews with top experts from around the world.
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