A Case of Aphantasia

By Dustin Grinnell

In this short story, a fictional technology gives a man the ability to visualize anything in his mind’s eye. With an increasingly stronger imagination, the man struggles to stay in the real world and must rely on family to free him from the grips of his own mind.

A few years ago, I began treating a thirty-five-year-old man, whom I will refer to as Theodore. Theodore had a rare and only recently discovered condition known as aphantasia, which left him unable to visualize images in his mind. For example, if Theodore closed his eyes to visualize a sunset, he saw only blackness. About two percent of the population has aphantasia, but many—Theodore included—don’t see it as a handicap but rather as a quirk of their imagination, perhaps not unlike living with color blindness.

Theodore did confess once that it would be nice to be able to picture a childhood memory in his mind’s eye, like the face of his deceased grandmother. Indeed, our therapy was often hampered because Theodore could not call to mind images from his past. When PhotoMind became available through the Cambridge-based technology company Envision Inc., it became an important tool in Theodore’s treatment, allowing us to obtain total visual recall of Theodore’s past on a computer monitor.

In therapy sessions, I am always searching for what the pioneering psychoanalyst Melanie Klein calls the point of urgency—an idea that is just about to leap from a patient’s unconscious and into conscious awareness. I listen deeply to my patients, searching for and identifying the points of urgency. As gracefully as I can, I introduce the ideas into conversation, so they may be taken up and integrated, no longer split off from consciousness, bound to cause distress or dysfunction.

Several months into my course of therapy with Theodore, I realized a point of urgency for him revolved around women—fear of abandonment, issues with intimacy, and the serial monogamy that resulted from an inability to committ to the opposite sex. I speculated that his problems with women were associated with a strained relationship with his mother and the eventual loss of his grandmother, who had become his primary caregiver after his parent’s divorce when he was six.

Theodore told me casually that his mother had left town for a year after divorcing his father, leaving Theodore and his younger brother in the care of their father. We speculated about why his mother had left, and he suggested that she was young and perhaps she had felt burdened by the responsibilities of parenthood. For years, Theodore had wondered whether his mother loved him. However, he told me that it was more realistic that she loved him a great deal but was tragically unable to express that love in tangible, meaningful ways.

I helped Theodore understand that perhaps his fear of being abandoned by women stemmed from an absence of his mother and was then driven deeper by the death of his grandmother when he was a teenager. It was a tremendous insight. In therapy, we reflected on the two incidents so as to make sense of them.

With the advent of PhotoMind, Theodore and I witnessed crucial moments from his childhood. Together, we watched the day his father told him that his mother was leaving. On the screen, we saw a young Theodore angrily pull at his hair until it stood straight up and then bury his head in his hands and scream.

About a year into our sessions using PhotoMind, Theodore began to report what I would refer to at a psychiatric conference as the “unintended consequences of stimulated visual recall”: involuntary images intruding into his conscious awareness. At first, the mental images were only a curiosity to him.

One day, Theodore was waiting in line at the supermarket when images of his dying grandmother, struggling for air in a hospital room, rushed into his head, startling him. On another occasion, he said he experienced a rush of mental images from the time he left his mother’s house to study abroad for six months. After saying goodbye and getting into his car to leave, he had stepped out once more, walked back to where his mother was standing, and gave her one last hug.

When we rewatched these memories with PhotoMind, he told me it was bittersweet to “see” these moments again. The mental movies produced strong emotions that were, at times, overwhelming. Then the intrusive images began to happen with more regularity.

Eventually, our sessions shifted to the management of the mental pictures, which Theodore reported to be increasingly burdensome. In one session, he confessed to wishing he could go back in time to when he couldn’t picture images in his imagination.

To manage the intrusive images, Theodore began to employ various coping mechanisms. He would play—rather obsessively, I expressed to a colleague—games on his phone that were of a highly visual nature to distract his mind from invading imagery. Though concerned, I did not discourage this coping behavior.

In therapy, it became obvious whenever Theodore’s mind was overwhelmed with mental imagery. He might be in the middle of a sentence when he would shut his eyes and press his palms against his temples. Sometimes, he would rip the PhotoMind wires from his head in frustration. Once, when a particularly intense rush of images took hold, he pulled a small patch of hair from his scalp.

It occurred to me at one point that PhotoMind had, in fact, cured Theodore’s aphantasia. However, it had unwittingly produced its opposite state: hyperphantasia, the ability to see images in one’s mind as if they were photographs. Now a hyperphantasic, Theodore likened his mind to a camera; he could create mental pictures rich with color and nuance and could move and rotate objects in space with or without his eyes closed. Theodore reported that he no longer watched a movie twice. Why would he when we could rewatch it in his mind?

Unfortunately, Theodore’s extraordinary new capacity had come at an unexpectedly deep cost. Over the ensuing months, Theodore grew more distressed as visual images continued to intrude unexpectedly, with greater regularity and more vividness. He lamented that he was now “drowning” in pictures. The micro-expression of an acquaintance or colleague could stick in his mind like a splinter, disturbing him weeks after noticing it out of the corner of his eye. He reported that he could rewatch these moments—any moment—as if they were scenes from a film. He could fast forward and rewind a visual memory, stopping on individual frames.

In sessions, Theodore’s eyes might drift to the floor as he spoke. I once asked where his mind had traveled, and he told me he’d watched his sunglasses drop to the dirt from his head—a memory from when he was young. Not noticing they had fallen, his mother had accidently stepped on the sunglasses, destroying them. Though his mother had driven him to a store to buy new sunglasses, the memory seemed to upset him a great deal. Watching the scene play out on the screen Theodore’s eyes welled with tears.

Hoping to gain other perspectives from my colleagues, I published a case study about Theodore in a medical journal. While it was tempting to gush over the benefits of PhotoMind, I wrote a balanced account, turning quickly to the costs to my patient. In that paper, I shared a particularly poignant story from Theodore. During a walk, he had stopped to admire a tall birch tree. Within seconds, however, Theodore had conjured up an image of a much taller, more robust, and more visually striking tree in its place, making the real tree an inferior version of the imagined one.

Distressed by such dislocations from reality, Theodore took up Zen meditation as a way to stay anchored in the present. However, the imagined world was becoming more intrusive and, to his dismay, more appealing.

Why focus on a real tree, he mused, when the imagined tree was more beautiful? The real tree was bent in the middle, ravaged by invasive insects, and dehydrated from a hot summer, but the imagined tree was mightily tall and glowing healthily. The tree in his mind was perfect.

Though Theodore was initially conflicted by this apparent escape from reality, he was putting his ability to positive use. For example, if he felt bored at work, he would mentally dislocate himself and slip into the imagined world. He once replayed a previous night’s dream, in which he had taken the form of a seagull and floated on thermal vents high above the sand dunes of Cape Cod, occasionally spotting a crab and making the exhilarating dive toward earth for a meal.

Theodore also told me he was no longer as vulnerable to the mental health troubles that had previously plagued him. Whenever he felt the sting of loneliness, for instance, he would create a mental movie in his mind of times in college when he had felt a deep sense of companionship with friends. This might have manifested as enjoying meals in the college cafeteria or tossing the rugby ball with teammates. He confessed that the habit could have started because he was meeting up with friends and coworkers less. I suspected that his real-life interactions weren’t as pleasurable as the idealized past.

In what turned out to be our last session together, Theodore pictured his mother running down the stairs in a bath towel after a bookcase had caught fire. Exploding out of his seat, he called my PhotoMind machine “the devil” and proceeded to smash it against the wall, shards of plastic and metal flying in all directions. The incident cost me a great deal, but I brought no charges against Theodore and insurance covered the damages anyway.

After Theodore had calmed, I told him we would discontinue treatment with PhotoMind. He seemed pleased, and I looked forward to establishing a new normal with him. However, I never heard from him after that session. He didn’t answer my phone calls or emails. He simply disappeared.

Several months later, I received a phone call from a psychiatrist at Envision Inc, named Dr. Banks. Dr. Banks had read my case study of Theodore and wanted to know how long I had treated him using their technology. After answering her question, Dr. Banks told me that Theodore was now in her care at the company and that I could visit him if I wanted. I was not told the reason for the invitation, but I sensed a desperation in her voice, as though she and others had failed to help Theodore and were grasping for an outside perspective. I told her I would be there in forty-five minutes.

When I saw Theodore on the third floor of Envision Inc., he was alone in the room, slumped in a chair. His face had grown scruffy, and an orderly informed me that he hadn’t showered since he’d been admitted two weeks before. Though he sat in front of a television, Theodore’s eyes were fixed on the corner of the room. I rounded the chair to see a string of drool hanging from his lips.

I greeted him but received no response. He appeared to be intensely preoccupied. I used a tissue to wipe the drool from his mouth and left the room to rejoin Dr. Banks in the hallway. Dr. Banks offered the possibility that Theodore had suffered a psychotic break. I hesitated to deliver any diagnosis at first; we were in uncharted territory. It was obvious that Theodore was lost in mental images. Whether he was reliving a memory or rewatching a movie, whatever he was experiencing had completely disconnected him from his physical environment.

As we talked in her office, Dr. Banks asked if I had spoken to others about Theodore. I hadn’t said anything to anyone since he disappeared, which Dr. Banks seemed glad to hear. She asked me to sign a confidentiality agreement, stipulating that I not discuss what I was about to see with anyone, under penalty of legal action. After signing the agreement, Dr. Banks led me to an elevator that took us one floor below ground. I was invited into what looked like a hospital emergency room, a large open floor with exam rooms along the perimeter. I was struck by something that made me uneasy. Total silence.

Dr. Banks slid open one curtain to reveal a young boy seated at the edge of his bed, staring at the ground, in the same way Theodore had been looking at the corner of his room. Dr. Banks snapped her fingers in front of the small child, which elicited no reaction, and then told me she was treating about a dozen people like him. No doubt there were more they were not aware of.

She and her colleagues were privately calling these patients “the lost ones.” After treatment with PhotoMind, these aphantasic had become hyperphantasics: off the charts in their capacity to form static or moving images in their minds. The technology was good, Dr. Banks gloated, but—she added with some uneasiness—they had not anticipated the repercussions of making it too good.

The lost ones weren’t at the mercy of their minds. The mental imagery could, at times, be intrusive, but they could usually shut down the images. Instead, the lost ones had chosen to stay with their mental movies. Some lost ones, Dr. Banks explained were wrapped up in memories from childhood. Some were binging on television shows. One man had spent hours engaging in sexual acts with his female boss. Others played out fantasies of revenge: one woman stabbed an unfaithful lover, while one man smashed his car into another’s during a bout of road rage.

Since I only had an average ability to visualize mentally it had never occurred to me that someone might choose to live inside their head rather than engage with the real world. After some thought though, I understood that within such a mental space, one could do whatever—be whoever—they wanted.

In the real world, we pay taxes and bills and toil away at jobs for salaries that help us buy things beyond necessities. In the world of perfect mental creation, one could instantly lose forty-five pounds, smack an inconsiderate coworker across the face, or transform a traumatic childhood into a harmonious one. If one were so inclined, one could lift off the ground and fly around the city.

However, a person must still eat, drink, sleep, and use the bathroom. When I brought this up, Dr. Banks assured me that if I stuck around the ward long enough, I would see the lost ones speedily visit the toilet or take a few bites from an apple before retreating to their rooms and back into the haven of their minds.

I began to realize that there are always tradeoffs with any technology. If humans want to fly, we have to accept that some planes will go down. The invention of the automobile gave us great freedom, yet more than three thousand people die every day in car crashes. The question is this: do the benefits of our inventions outweigh the inevitable costs?

We can’t foresee all the possibilities at the start of something, but I wonder if I had contributed to Theodore’s handicapped state. Should I have stopped treating him at the first sign of distress? The technology’s potential had excited me. I had been testing the boundaries of PhotoMind with Theodore, but had I pushed it—him—too far? Theodore had had to destroy my machine before I discontinued treatment.

That day, I left Envision Inc. disturbed, but I knew I had to see Theodore again, so I visited him the next day. I wondered if there might be a way to coax him out of the illusory world by reminding him of reality, so I brought an object that might trigger a thought perhaps more appealing than his dreams.

When I walked into his room that day, I put a picture of his mother before him. To my delight, his eyes focused on the image of him as an infant resting happily on his mother’s lap. Theodore grinned and set the picture on his knee, but then his eyes fell to the floor and locked into place. I had lost him again.

I asked him to stay with me. To my surprise, he returned to the present and made eye contact with me. He said he had been spending a lot of time with his mother in his mind. He was not reliving experiences like the one in the picture but rather creating new ones with her. They would go on hikes together or sit around the fire in her backyard and share stories. In real life, his mother was distant and unreachable, but in his mind, he could communicate his ideas and hopes to her. In his mind, she was available and loving. In his mind, she was the mother he had always wanted.

It occurred to me that that kind of imaginary play was in some ways therapeutic. Such mental imagery was soothing, a form of self-care, but there was too much dysfunction to justify the possible benefits to Theodore’s mental health. Like the other lost ones, he left his room only to use the bathroom, eat, or drink, after which he would retire to his room and dislocate from reality again. Not to mention, he was unemployed and in the full-time care of licensed mental health professionals.

What I did next was undoubtedly overstepping my boundaries, perhaps even violating some code of conduct—many of my colleagues have said my license should have been revoked for what I did—but I saw no other way to snap Theodore out of his imagination. I had grown attached to him. I liked him and hated to see him this way.

After my second visit with Theodore, I drove three hours north and knocked on the door of his mother’s house. After I explained Theodore’s situation over coffee, his mother, Stephanie, seemed desperate to help. She told me that she was estranged from her son for no particular reason. They had ultimately reconciled over her disappearance in childhood and yet they had grown distant over the years, anyway. No major event had happened between them. No bad blood. Just distance.

I asked her to elaborate, and Stephanie told me that her son’s intelligence intimidated her. Theodore was a smart, driven man, and she feared she had nothing to offer him. In the rare cases that she reached out with a text or phone call, she worried that she might be bothering him, somehow pulling him away from his work that seemed to be his highest priority. The inability to connect with her firstborn appeared to cause Stephanie great distress.

When I explained to her that Theodore was among the lost ones, she burst into tears. Somehow, she made it her fault, but I assured her that her son’s slippage was accidental. Minutes later, Stephanie became mobilized, gathering her things haphazardly and nearly forgetting to unplug her hair straightener as she left the house and jumped into the passenger seat of my car.

Hours later, when Stephanie wrapped her arms around Theodore, it was as though a grenade had gone off in the room. Theodore leaped maybe two feet out of his seat. Yet after her embrace, he blinked a few times, settled himself, and then drifted back into the mental imagery of his mind.

At first, Stephanie was confused—“What’s the matter?”—then angry—“How could he ignore me like this?” Then she became despondent. Crying, she tried to snap her son out of his imagination by grabbing his shoulders, shaking him, and to my astonishment, slapping him across the face. In that moment, Theodore began sobbing, but even with tears streaming down his face, he remained absent, fixed on his imagined world.

It was heartbreaking to watch.

An internal struggle took place then. Theodore’s eyes went in and out of focus. He was with us, then he was gone, and then he was back again. The only explanation I could think of was that his consciousness didn’t know where to land. It kept shifting from his mother in his imagination to his mother in the room. Faster and faster, he switched between them, searching for the love he needed.

I have come to believe that the two realities melded in Theodore’s mind that day. He came to believe, in an instant, that the mother of his mind was the same as the one before him—that the detachment he experienced with her was no fault of hers nor of his. That beneath the disappointments, insecurities, and failures of his mother was the loving mother his mind had conjured. The distance between the two mothers vanished, as did the distance he felt toward her. They became one.

It was obvious from Theodore’s expression that some battle in his mind had been won. Stephanie rubbed the back of his neck as he shook his head and stretched his arms up. Stephanie’s face then hardened into a steely determination. She told me to leave the exam room and start my car, and I did.

What happened next is a matter of public record; surveillance cameras recorded the events.

From the driver’s seat of my car, I watched the massive window in Theodore’s room shatter. Shards of glass rained down onto the manicured lawn. Standing at the broken window were Stephanie and her son, Theodore’s arm slung around her shoulder. Security guards ran into the building’s front doors, and Stephanie guided her son onto a fire escape outside the window. Theodore appeared lucid as he negotiated the descent down the building. Behind him, Stephanie scrambled down. Theodore guided his mother to the ground, and together, they sprinted toward my car.

Theodore dove into the passenger seat, and his mother slid into the back. Theodore was wearing a smile I hadn’t seen in all the time I had known him. His mother was laughing. I put the car into reverse and stepped on the accelerator, leaving tread on the pavement as I sped toward the exit. With an excitement I haven’t felt since, I reached an improbable speed in the company’s parking lot and—I still can’t believe I did it—smashed straight through the lowered front gate. Shards of wood flew in all directions.

Right afterward, Theodore unbuckled his seatbelt, lifted his torso out of the passenger-side window, and screamed, a primal yell, a release from a big sleep. I looked in the rearview mirror and couldn’t tell if his mother was laughing or crying.

We were all euphoric.

At Theodore’s request, we just drove and drove.

                                               ************************
Dustin Grinnell is a writer based in Boston, with interests in storytelling and medicine. His creative nonfiction has appeared in The LA Review of Books, The Boston Globe, New Scientist, VICE, Salon, and Hektoen International, among others. He is also the author of The Genius Dilemma and Without Limits. He holds a BA in psychobiology from Wheaton College (MA), an MS in physiology from Penn State, and an MFA in fiction from the Solstice program in Chestnut Hill, MA. He works as a staff writer for a hospital in Boston. See more at his website.

 

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One comment on “A Case of Aphantasia

  1. humanemedicine on said:

    Brian Maurer, a pediatric practitioner from Connecticut left these comments:
    “In this fictional narrative, Dustin Grinnell explores the mesmerizing effects of digital technology on the human brain. Through the guidance of a well-meaning therapist, an unsuspecting patient finds himself pulled into a world of virtual reality from which he eventually becomes powerless to extricate himself. Only one intervention is capable of breaking the spell: love, expressed through a concerned significant other. The final lines of Thornton Wilder’s “The Bridge of San Luis Rey” come to mind: “But soon we shall die … and we ourselves shall be loved for a while and forgotten. But the love will have been enough; all those impulses of love return to the love that made them. Even memory is not necessary for love. There is a land of the living and a land of the dead and the bridge is love, the only survival, the only meaning.”

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