Far adrift from the subcontinent in the remote waters of the Indian Ocean exists two islands named Lilliput and Blefuscu. These otherwise unremarkable islands are inhabited by a race of homunculi of approximately 15cm in height; at least this is what Jonathon Swift in his novel Gulliver’s travels would have us believe.
It is the first of these islands which is the namesake of a psychiatric phenomenon known as lilliputian hallucinations which were first described in 1909 from the personal experiences of French Psychiatrist Raoul Leroy.
Described as from 1mm to 1m tall in populations as large as several million at a time these hallucinations can overwhelm those afflicted by them. Dirk Blom estimates a prevalence of lilliputian hallucinations of 30-80 per 10,000 psychiatric patients, making them far less common than other forms of visual hallucination. They also show remarkable variation in both attire and personality with dancers, soldiers, clowns and gnomes amongst common character presentations.
Historically these hallucinations were believed to be relatively benign in their interactions with the patient but new research suggests that this is not so with 46% of patients attributing negative characteristics towards them such as “frightening” or “menacing”. Whilst this is not the most flattering appraisal of the Lilliputian, it thankfully stops short of Swift’s creations which are the victim of this delightful tirade. “I cannot but conclude that the Bulk of your Natives, to be the most pernicious Race of little odious Vermin that Nature ever suffered to crawl upon the Surface of the Earth.”
Causes of lilliputian hallucinations are varied, including Lewy-body dementia (approx. 5% of dementia cases), schizophrenia and alcohol induced psychosis. It is the last of these which has led to some rather tongue-in-cheek suggestions that the hallucinations represent a potential origin story of the Irish Leprechaun.
Due to the range of potential causes for these hallucinations’ treatment is also varied dependent on the underlying pathology. Unfortunately, for many patients the underlying pathology may be progressive in nature and without significant treatment. One can only hope that with the continued advance of medical science we will be better equipped to tackle the challenges we face, no matter how small.
