Complex Visual Hallucinations, Presumably Due to Subarachnoid Hemorrhage, Treated Successfully With Risperidone

Visual release hallucinations, also known as Charles Bonnet Syndrome, is a fairly common condition that goes unrecognized by more than 50% of all physicians. The syndrome is characterized by complex visual hallucinations in patients who have experienced partial or complete loss of vision. The hallucinations are exclusively visual in nature, usually temporary, and unrelated to mental and behavioral disorders. To make the diagnosis of CBS, patients must maintain some degree of insight into the unreal nature of their visual experiences, with an absence of delusions and hallucinations in other sensory modalities. This case report details a 93-year-old male with a history of mild cognitive impairment and bilateral cataracts who was found to have visual release hallucinations on hospital admission. The purpose of this case report is to increase awareness for Charles Bonnet Syndrome as a potential cause of visual hallucinations, particularly in elderly patients with a history of visual impairment.

To the Editor: Complex visual hallucinations are usually a sign of acute psychopathology or gross cognitive impairment: they have been reported in patients with senile dementia, late paraphrenia, epilepsy, malignant hypertension, tumors, and adverse drug reactions.1 However, they may also occur in people with an ophthalmologic disorder: the Charles Bonnet Syndrome is a condition in which otherwise healthy individuals, i.e., without demonstrable psychopathology, experience vivid visual hallucinations.2–4 An analysis of the 64 cases reviewed by Schultz and Melzack reveals that the syndrome can occur at any age though it is more common in elderly people.5 During the last year, three very old patients, two nonagenarians and an 87-year-old woman, have come to our observation for “pleasant” complex visual hallucinations. A male, 93-years-old, with a university education, is in general good health and suffers from a mild degenerative joint disease, predominantly affecting his left hip; there is no history of major diseases. The content of his hallucinations is the representation of flowers (cyclamens’ fields, floods of wistarias and lilacs), Renaissance paintings, Chinese tapestries, and monumental squares. Hallucinatory symptoms have occurred with a frequency of once/twice a week during the last year. This patient is unimpaired in basic and instrumental activities of daily living. His mental status is good, with a MMSE score of 29/30. His Geriatric Depression Score is 7/30. There is no evidence of psychopathology either anamnestic or present. There is no family history of mental diseases. Neither epileptiform activity nor pathological slow activity was observed during basal registration or hyperventilation on EEG. A female, 92-years-old is a noblewoman with a secondary school education. She is only moderately hypertensive and is taking Enalapril 10 mg daily. She is in very good health and has no history of major somatic disease. The content of her visual hallucinations is characterized by flowers (chrysanthemums and orchids) and by tropical plants and trees, paintings (such as Botticelli's Spring), golden frames, and silk curtains floating in the wind. Hallucinatory symptoms have occurred three/four times a month during the last 3 months. Her MMSE score is 30/30. She does not suffer from depressive symptoms (GDS = 3/30). She is completely self-sufficient in both ADL and IADL functions. There is no evidence of psychopathology, either anamnestic or present. There is no family history of mental diseases. Neither epileptiform activity, nor pathological slow activity was observed during basal registration or hyperventilation on EEG. This is an 87-year-old female with primary education background. She suffers from a recent hip fracture caused by an accidental fall. Her MMSE is 25/30, and her GDS score is 10/30, indicating a mild degree of depression. Before the fracture she was completely self-sufficient in both ADL and IADL functions. The content of her hallucinations is poorer than the previous two cases, but equally pleasant: little geometrical and colorful flowers, floral tapestries, mountain brooks, clouds moving fast in the sky, and waves crushing on the shore. Hallucinatory symptoms occurred once/twice a week during the last 3 years. In this old lady, as well, there was no evidence of psychopathology, anamnestic or present, nor was there a family history of mental diseases. EEG showed a normal posterior alpha rhythm at 10 Hz, bilateral and synchronous, with short periods of theta rhythm (7 Hz), especially during hyperventilation. No epileptiform nor pathological slow activity was detected. The only common trait among the patients was the presence of ocular pathology. The 93-year-old man (Case 1) suffers from bilateral cataract and from the sequelae of a previous occlusion of the central retinal vein in his left eye. Visual acuity is 20/30 in the right eye, and the left eye is completely blind. The 92-year-old woman (Case 2) suffers from a cataract reducing her visual acuity to 18/30 in the right eye and from an opacity of the lens outside the left visual axis; presently, there is no indication for surgery. The visual evoked potential revealed a normal bilateral N75 response and a slightly delayed bilateral P100 response: right eye 113 msec, left eye 112 msec (laboratory range = 91–110 msec). Wave amplitude was normal in the left and reduced in the right eye. The second woman (Case 3) suffers from bilateral cataracts, reducing visual acuity in her left eye to 1.5/30 and in her right eye to 15/30, for which there is an indication for surgery extraction. The visual evoked potential showed a bilaterally delayed P100 (right eye 126 msec, left eye 125 msec) with a normal amplitude in the left and reduced in the right eye. In all three cases, the onset of the hallucinations was not associated with a detectable change of vision; hallucinations are stopped by focusing attention on a specific object. Results are consistent with earlier reports suggesting that these hallucinations are not due to psychopathology or compromised cognitive functioning. Our patients do not suffer from mental disorders, and their insight is good. Because there are not symptoms of mental diseases, it could be proposed that complex visual hallucinations represent ongoing neural activity in the visual system following eye damage. Sensory deprivation might produce patterns of nerve impulses that give rise to visual experiences.5 Complexity of hallucinations is probably attributable to the degree of schooling and culture of the patients: the richer the cultural background, the greater the complexity of psychic symptoms. Occurrence of visual hallucinations in old age is frequently described, but, in general, they are negative and unpleasant symptoms of mental diseases or the phenomenon of adverse drugs effects. In our three very old patients, emotional reactions to the visual hallucinations were positive and perceived as pleasant; the 92-year-old woman was only worried that the symptoms were prodromes of impending death (is it Heaven?). Literature observations suggest that the Charles Bonnet Syndrome is frequently overlooked or misdiagnosed by both ophthalmologists and psychiatrists. This may be true also for geriatricians.

P03-91 Charles Bonnet Syndrome and vitamin B12 deficiency: A case report

Charles Bonnet, His Life, and His Syndrome

Charles Bonnet Syndrome (CBS) has been defined as complex visual hallucinations (CVH) due to visual loss. The underlying mechanism of CBS is not clear and the underlying pathophysiology of the visual hallucinations in CBS patients and pure visually impaired patients is still not clear. In our study, we have scanned three patients with eye disease and CBS (VH+) and three patients with eye disease without CBS (VH-) using FDG-PET. Our results showed underactivity in the pons and overactivity in primary right left visual cortex and inferior parietal cortex in VH- patients and underactivity in left Broca, left inf frontal primary visual cortex and anterior and posterior cingulate cortex in VH+ patients relative to the normative 18FFDG PET data that was taken from the database consisting of 50 age-matched healthy adults without neuropsychiatric disorders. From this distributed pattern of activity changes, we conclude that the generation of visual hallucination in CBS is associated with bottom-up and top-down mechanism rather than the generally accepted visual deafferentation-related hyperexcitability theory.

The rarity of Charles Bonnet syndrome

Charles Bonnet syndrome (CBS) is a rare clinical condition characterized by complex visual hallucinations in people with loss of vision. So far, the neurobiological mechanisms underlying the hallucinations remain elusive. This case-report study aims at investigating electrical activity changes in a CBS patient during visual hallucinations, as compared to a resting-state period (without hallucinations). Prior to the EEG, the patient underwent neuropsychological, ophthalmologic, and neurological examinations. Spectral and connectivity, graph analyses and signal diversity were applied to high-density EEG data. Visual hallucinations (as compared to resting-state) were characterized by a significant reduction of power in the frontal areas, paralleled by an increase in the midline posterior regions in delta and theta bands and by an increase of alpha power in the occipital and midline posterior regions. We next observed a reduction of theta connectivity in the frontal and right posterior areas, which at a network level was complemented by a disruption of small-worldness (lower local and global efficiency) and by an increase of network modularity. Finally, we found a higher signal complexity especially when considering the frontal areas in the alpha band. The emergence of hallucinations may stem from these changes in the visual cortex and in core cortical regions encompassing both the default mode and the fronto-parietal attentional networks.

<p>Charles Bonnet syndrome (CBS) was first described by Swiss philosopher Charles Bonnet in 1760. The defining characteristics of the syndrome include visual impairment, complex visual hallucinations, preservation of mental competence, and insight. The syndrome is an infrequently diagnosed but rather common cause of complex visual hallucinations. Its prevalence in patients with visual impairment varies from 10% to 15%, and it occurs most commonly in elderly people. The common conditions leading to the syndrome are age-related macular degeneration, glaucoma, and cataract.</p> <h4>ABOUT THE AUTHORS</h4> <p>Nahla Mahgoub, MD, is Staff Psychiatrist, Weill Cornell University-Westchester Division, New York. Michael Serby, MD, is Professor of Clinical Psychiatry, Beth Israel Medical Center, Albert Einstein College of Medicine, New York.</p> <p>Address correspondence to Dr. Mahgoub via e-mail at: <a href="mailto:NAMD06@aol.com">NAMD06@aol.com</a>.</p> <p>Dr. Mahgoub and Dr. Serby have disclosed no relevant financial relationships.</p> <h4>EDUCATIONAL OBJECTIVES</h4> <ol> <li>Identify the common clinical features of Charles Bonnet syndrome.</li> <li>Discuss potential treatments for Charles Bonnet syndrome.</li> <li>Name the type of disorder of which Charles Bonnet syndrome is comprised.</li> </ol>

Visual hallucinations are a common and often distressing consequence of vision loss, particularly in age-related macular degeneration. Charles Bonnet Syndrome (CBS) is defined by the triad of complex visual hallucinations, ocular pathology causing visual deterioration and preserved cognitive status. So far, although this condition is frequent, no established treatment for CBS has been stated. We report here the case of a 78-year-old woman, who came in our hospital because of a 4-week long mild depressive symptomatology. For 1 year she experienced daily sudden, unexpected, vivid and elaborate hallucinations. Insight was completely present, so the patient stated that the hallucinations were unreal and that the faces, geometrical figures and animals she saw every day were possibly due to her vision loss. The Mini Mental State Examination, digit span and verbal fluency were administered and no cognitive impairment was reported. The visual acuity was hand motion. After 4 days of treatment with venlafaxine the hallucinations completely disappeared. This is the first case to show that selective serotonin (and noradrenalin) reuptake inhibitors may be an effective and well-tolerated treatment for visual hallucinations associated with vision loss, and it adds to evidence implicating serotonergic pathways in the pathogenesis of visual hallucinations.

We report the case of a 76-year-old woman who presented with recurrent episodes of complex visual hallucinations in her right visual field without an anopsia. The electroencephalogram showed sharp transients in the left parietotemporal region with phase reversals at T5 and P3. FLAIR MRI revealed hyperintense lesions in the left temporo-occipital lobe, located mainly in the left inferior temporal lobe. Cerebral angiography revealed an arteriovenous shunt from the left occipital artery to the left transverse sinus with cortical venous reflux. The complex visual hallucinations were resolved after transarterial embolization. We therefore hypothesize that this patient's complex visual hallucinations were caused by epileptic seizures or changes in cortical blood flow caused by the cortical venous reflux from the arteriovenous fistula. In general, epileptic hallucinations expand into the bilateral visual field. We reveal that in rare cases, complex visual hallucinations can also be limited to the unilateral visual field without an anopsia. Additionally, we reveal that a dural arteriovenous fistula can cause visual hallucinations without hemianopia.

Charles Bonnet syndrome (CBS) is characterized by recurrent or persistent complex visual hallucinations that occur in visually impaired individuals with intact cognition and no evidence of psychiatric illness. Patients usually retain insight into the unreal nature of their hallucinations.3,4 CBS is often misdiagnosed, and predominantly affects elderly patients with vision changes (e.g., age-related macular degeneration, glaucoma, and cataract). While many require only the assurance of the benign nature of the hallucinations, nonpharmacological and pharmacological interventions have been reported to be useful in the treatment of CBS. This case involves an 83-year-old female, with a two-year history of CBS, who presented to the clinic with worsening visual hallucinations over the past few months. She was starting to lose insight into her hallucinations secondary to her new diagnosis of dementia. Several pharmacological agents were explored to determine the most appropriate choice for our patient. Ultimately, this patient was started on donepezil (reported to be successful in a CBS case report), which helped improve her cognitive function. At future follow-up visits, her hallucinations improved and her cognitive function stabilized. Pharmacists should be aware of CBS and its treatment options to properly assist physicians in the medication-selection process to alleviate distress experienced by patients with CBS. In patients who may benefit from pharmacological treatment, physicians should weigh the risks and benefits of the different treatment options. Donepezil can be a favorable option in CBS patients with Alzheimer's type dementia.

Charles Bonnet syndrome (CBS) presents with complex visual hallucinations in visually impaired individuals with preserved insight. While most commonly associated with macular degeneration, it may occur in glaucoma. CBS is often under-reported due to stigma and may progress to psychiatric morbidity. A 63-year-old man with bilateral visual loss following acute angle-closure glaucoma experienced vivid hallucinations of animals and snakes. Initially concealed due to embarrassment, the symptoms were revealed during psychiatric assessment. Ophthalmic evaluation confirmed glaucomatous changes; MRI brain was recommended but declined. CBS was diagnosed, and hallucinations resolved with reassurance and low-dose clonazepam. Several weeks later, the patient developed moderate depression (HAM-D = 18), successfully treated with mirtazapine. At three months, he remained asymptomatic. This case is unusual for its association of CBS with angle-closure glaucoma and subsequent depression, underscoring the need for proactive inquiry, de-stigmatization, and integrated ophthalmic–psychiatric care.

We report a patient’s challenging case who suffered two acute ischaemic strokes, first in the right occipital lobe and later in the right dorsolateral thalamus (with affection of the lateral geniculate nucleus) who developed a yellow-tinted left homonymous visual hemi-field. No previously described case matched our peculiar symptom presentation in combination with the described brain lesions. Especially, the visual phenomena of patients with these brain lesions that were up until now described in literature were complex and vivid visual hallucinations. Here, we discuss possible explanations and mechanisms of this visual phenomenon (acquired hemidyschromatopsia, peduncular hallucinosis, focal epilepsy with visual symptoms, visual hallucinations) and in light of the current literature, we argue that the most likely explanation is a form of simple visual hallucination due to release phenomena (Charles Bonnet syndrome).

Objective: Charles Bonnet Syndrome (CBS) consists of visual hallucinations occurring in patients with visual impairment. CBS is commonly overlooked by medical professionals and underreported by patients due to the underlying stigma attached to the presence of hallucinations. Lack of awareness regarding CBS among medical professionals may lead to failures in providing forewarning and education to patients with visual impairment. In patients who are not familiar with CBS, this might lead to a higher risk of distress, misattribution to cultural belief or mental illness, and the potential of developing psychosis, especially in elderly patients with other modalities of sensory deprivation. This case report aims to increase awareness and knowledge about CBS among clinicians for the proper management of patients.Method: This case illustrated a patient with worsening visual impairment who presented with typical CBS and later progressed to visual hallucination and persecutory delusionResults: Providing information on CBS and antipsychotics resulted in less distress and improved the patient’s visual hallucination and delusionConclusion: Education and reassurance play a role in the management of CBS. It is important for medical professionals to be aware of CBS and provide clear information for patients who are at risk to lower their distress.

Back to table of contents Previous article Next article LETTERFull AccessInsight in True Charles Bonnet SyndromeKurt Segers M.D.,Kurt Segers M.D.Search for more papers by this author,Published Online:1 Apr 2010https://doi.org/10.1176/jnp.2010.22.2.247.e1AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: In a recent issue of your journal, Gupta et al. 1 described two patients who are said to suffer from true Charles Bonnet syndrome. 1 Although there is no universal consensus about the diagnostic criteria of Charles Bonnet syndrome, the prefix “true” suggests the most stringent criteria and, in particular, the presence of full insight into the hallucinatory nature of the images together with the absence of cognitive decline. 2 Interestingly, many patients seem to pass through an initial phase of deception before recognizing the unreality of these images. 3 However, the 60-year-old man reported by Gupta and colleagues has a 6-year history of abnormal behavior (washing his hands, trying to get rid of the bugs on his food and clothes) directly related to the lack of insight in the hallucinatory nature of the bugs he sees. Therefore I suggest not to use the term “true Charles Bonnet syndrome,” and maybe not even the term Charles Bonnet syndrome for his condition, especially since Charles Bonnet himself stressed in his original description of the syndrome the fact that the patient was healthy and had a normal judgment and memory. 4 It would be more adequate to use the descriptive term “complex visual hallucinations” rather than an eponym. Memory Clinic of the Neurology Department, Memory Clinic of the Geriatric Daycare Hospital, Brugmann University Hospital, Brussels, Belgium