Charles Bonnet syndrome and multiple sclerosis

Cognitive Decline in Older People with Multiple Sclerosis—A Narrative Review of the Literature

Several important questions regarding cognitive aging and dementia in older people with multiple sclerosis (PwMS) are the focus of this narrative review: Do older PwMS have worse cognitive decline compared to older people without MS? Can older PwMS develop dementia or other neurodegenerative diseases such as Alzheimer’s disease (AD) that may be accelerated due to MS? Are there any potential biomarkers that can help to determine the etiology of cognitive decline in older PwMS? What are the neural and cellular bases of cognitive aging and neurodegeneration in MS? Current evidence suggests that cognitive impairment in MS is distinguishable from that due to other neurodegenerative diseases, although older PwMS may present with accelerated cognitive decline. While dementia is prevalent in PwMS, there is currently no consensus on defining it. Cerebrospinal fluid and imaging biomarkers have the potential to identify disease processes linked to MS and other comorbidities—such as AD and vascular disease—in older PwMS, although more research is required. In conclusion, one should be aware that multiple underlying pathologies can coexist in older PwMS and cause cognitive decline. Future basic and clinical research will need to consider these complex factors to better understand the underlying pathophysiology, and to improve diagnostic accuracy.

Hallucinations Experienced by Visually Impaired: Charles Bonnet Syndrome

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Charles Bonnet Syndrome is a condition where visual hallucinations occur as a result of damage along the visual pathway. Patients with Charles Bonnet Syndrome maintain partial or full insight that the hallucinations are not real, absence of psychological conditions, and absence of hallucinations affecting other sensory modalities, while maintaining intact intellectual functioning. Charles Bonnet Syndrome has been well documented in neurologic, geriatric medicine, and psychiatric literature, but there is lack of information in optometric and ophthalmologic literature. Therefore, increased awareness of signs and symptoms associated with Charles Bonnet Syndrome is required among practicing clinicians. This review of the literature will also identify other etiologies of visual hallucinations, pathophysiology of Charles Bonnet Syndrome, and effective management strategies.

Seeing the unseen: Charles Bonnet syndrome revisited

Charles Bonnet syndrome (CBS) is a rare condition that encompasses three clinical features: complex visual hallucinations, ocular pathology causing visual deterioration, and preserved cognitive status. Common associated ocular pathologies include age-related macular degeneration, glaucoma, and cataracts. Several theories have been proposed to try to explain the visual hallucinations. However, the pathophysiology remains poorly understood, and treatment is largely based on anecdotal data. The lack of awareness of CBS among medical professionals often leads to inappropriate diagnosis and medication. In a country like India, where awareness of mental health is not widespread, cultural myths and stigma prevent patients from seeking professional help. Here we describe two cases of CBS and revisit different ocular morbidities that have been reported to occur in conjunction with CBS. Psychiatrists and ophthalmologists alike must be sensitive to this clinical condition to ensure prompt diagnosis and treatment.

Charles Bonnet syndrome: a literature review into diagnostic criteria, treatment and implications for nursing practice

Charles Bonnet syndrome is a disease of vision which may be mistakenly identified as manifestations of psychosis and consequently be treated by psychiatrists and mental health nurses rather than ophthalmologists. This literature review considers current understanding of the syndrome, its treatment and the role of mental health nurses. The two main findings of the review are that despite a long recognition of the syndrome, diagnostic criteria are not established and that there is no recognized evidence-based medical treatment. As well as this, two novel treatments which may offer future benefits are discussed. Current best practice is identified as identifying the condition and providing reassurance and education, a role that mental health nurses that are aware of Charles Bonnet syndrome can fulfil perhaps better than any other discipline.

Charles Bonnet syndrome: two case reports and review of the literature

Visual hallucinations (VHs) can be associated with a variety of clinical conditions, and are also experienced by healthy people due to visual impairment. The condition is known as Charles Bonnet Syndrome (CBS). The circumstances favoring VHs support the hypothesis that sensory deprivation enhances the ongoing activity of the visual system after sensory loss. Clinician should be aware that a significant proportion of visually impaired patients experience complex VHs, which are sometimes distressing. Herein, we report two cases of CBS. Case 1 is a 60-year-old man with visual impairment due to orbit pseudotumor in autoimmune hypothyroidism. Case 2 is an 87-year-old woman with Parkinson's disease and a 15-year history of intermittent complex VHs due to age-related macular degeneration in both eyes. In both cases investigations for alternative pathological causes of VHs were negative and, therefore, the aetiology of hallucinations was attributed to CBS. The course and treatment of CBS patients vary according to the nature of the visual dysfunction. Drug treatments remain partially satisfactory, with individual cases successfully treated with atypical antipsychotics. Nonpharmacological interventions aimed to reduce the visual pathway deprivation. Reassurance of the benign nature of CBS is essential to support patients and reduce caregiver's burden.

[Psychiatric, psychological comorbidities of typical and atypical Charles-Bonnet syndrome]

OBJECTIVES

Charles-Bonnet syndrome (CBS) is conventionally defined by the presence of visual hallucinations in patients suffering from lowered visual acuity without having psychosis or dementia. Actually, it is a syndrome that interests many specialties, especially ophthalmology, geriatrics, neurology and psychiatry. "Atypical CBS" or "CBS plus" was introduced to designate any kind of visual hallucinations that could be considered as a CBS but accompanied by a low level of insight, a possible cognitive decline, other hallucinatory modalities etc. Since all patients suffering from CBS have to be psychiatrically evaluated, psychological and psychiatric implications of their syndrome have to be well understood in order to better manage them. These psychiatric and psychological implications are: the relationship between the CBS and dementia, the psychological reaction of the patients towards their hallucinations and psychiatric comorbidities that could be developed during the course of the syndrome.

METHODS

A research via MEDLINE for all the articles published in French or in English between January 1999 and December 2009 was done using the following keywords Charles-Bonnet, psychiatric comorbidities and Charles-Bonnet syndrome, Charles-Bonnet syndrome and dementia, psychological reaction and Charles-Bonnet syndrome.

RESULTS

Although some studies report an association between the CBS and dementia, the majority of these studies do not confirm this association and point towards an atypical initial presentation of the syndrome. The psychological reaction accompanying the visual hallucinations of the typical CBS is variable (mild distress, indifference, pleasure). Patients suffering from a typical CBS conserve a full insight during the course of the syndrome. A positive personal psychiatric history or a concomitant psychiatric disorder changes the clinical presentation of the syndrome.

DISCUSSION

Our research allowed us to define the following diagnostic criteria for the atypical CBS: 1) diminished level or absence of insight towards the visual hallucinations; 2) presence of a mild cognitive decline; 3) presence of an atypical psychological reaction towards the visual hallucinations as in the case of a severe and prolonged stressful reaction; 4) presence of other hallucinatory modalities; 5) presence of a positive personal psychiatric history or a concomitant psychiatric disorder. Each patient suffering from CBS should be initially evaluated psychiatrically and neurologically in order to confirm or to eliminate the presence of the most common causes of visual hallucinations. In the presence of a lowered visual acuity and a conserved cognitive functioning, the typical CBS is diagnosed after eliminating more common disorders. Once this diagnosis is established, patients should be evaluated in order to rule out the presence of an atypical clinical presentation.

CONCLUSION

Atypical CBS is a syndrome that could be eventually associated with dementia, accompanied with a major depressive disorder or another psychiatric disorder, or with vulnerability towards psychiatric disorders. Patients suffering from atypical CBS should be closely followed psychiatrically and neurologically. Patients suffering from the typical CBS should also benefit from a psychiatric follow-up, due to their multiple psychiatric vulnerability factors and their possible management with psychotropic drugs.

A case of acute reversible Charles Bonnet syndrome following postsurgical unilateral eye patch placement

A fully alert 70-year-old male with no significant medical or psychiatric history presented for surgical follow-up after uncomplicated right lower eyelid cicatricial ectropion surgery with postoperative unilateral, eye patch placement complaining of visual hallucinations. Preoperative unaided visual acuity was 20/20 in each eye. The patient described simple, nonformed and complex, formed images that were both static and animated. The images included crystal-like formations that appeared to bubble, green leaves against a vivid magenta backdrop, and an isolated hallucination of a lifelike plant with trembling leaves. These hallucinations began 2 days postoperatively and persisted 2 days following eye patch removal. The patient perceived the hallucinations multiple times a day over the 7-day period, without a stereotyped pattern. The images occurred when the eyes were open and ceased when they were closed. They were prompted by looking at a blank wall or white surface. The patient consistently recognized these images as unreal. They typically persisted for 1 to 2 minutes and could be extinguished by looking away. There were no associated auditory hallucinations, psychosis, or delirium and no history of visual, cognitive, or neurological deficit. The patient denied the use of hallucinogenic medications, including analgesics, or the initiation of any new medications. To the authors' knowledge, this is the first reported case of acute reversible CBS following unilateral eye patch placement. CBS may be a frightening postsurgical consequence of eye patch placement. It is important that the ophthalmic surgeon be aware of the potential for development of CBS and offer appropriate referral and reassurance should it occur.

Charles Bonnet Syndrome Associated with a First Attack of Multiple Sclerosis

BACKGROUND

We treated a rare case of Charles Bonnet syndrome (CBS) manifested during temporary blindness in both eyes caused by optic neuritis associated with a first attack of multiple sclerosis (MS).

CASE

A 66-year-old Japanese woman became completely blind for 3 months due to optic neuritis after a first attack of MS. During the blind period, she experienced vivid visual hallucinations for about 2 weeks.

OBSERVATIONS

The patient had no psychiatric disorders or cognitive impairments; therefore, the visual hallucinations during the period of blindness were indicative of CBS. Unexpectedly, the hallucinations disappeared without treatment following her recovery of vision.

CONCLUSIONS

Although rare, visual impairment during a first attack of MS can be associated with visual hallucinations indicative of CBS. The hallucinations can disappear spontaneously with the recovery of vision without treatment.

Charles Bonnet syndrome: visual hallucination and multiple sclerosis

Multiple sclerosis (MS) is a fairly common condition that affects approximately 350,000 people in the United States. It is associated with various neuropsychiatric symptoms including cognitive and behavioral symptoms. However, visual hallucinations are rare in multiple sclerosis without the presence of cognitive deficits. We are describing the case of a 40-year-old married white female with isolated complex visual hallucinations compatible with the Charles Bonnet syndrome (CBS). The patient was successfully treated with the atypical antipsychotic olanzapine.

Complex visual hallucinations in the visually impaired: the Charles Bonnet Syndrome

Visually impaired patients may experience complex visual hallucinations, a condition known as the Charles Bonnet Syndrome. Patients usually possess insight into the unreality of their visual experiences, which are commonly pleasant but may sometimes cause distress. The hallucinations consist of well-defined, organized, and clear images over which the subject has little control. It is believed that they represent release phenomena due to de-afferentation of the visual association areas of the cerebral cortex, leading to a form of phantom vision. Cognitive defects, social isolation, and sensory deprivation have also been implicated in the etiology of this condition. This condition, which is most common in the elderly, frequently goes unrecognized in clinical practice, due to both lack of awareness among doctors and patients' reluctance to admit to hallucinatory experiences, for fear of being labeled mentally unstable. Furthermore, patients who comprehend the unreality of their hallucinations may be distressed by the real fear of imminent insanity. Sensitive and sympathetic history taking is essential to ascertain the existence of hallucinations. Reassurance and explanation that the visions are benign and do not signify mental illness have a powerful therapeutic effect. Hallucinatory activity may terminate spontaneously, on improving visual function or on addressing social isolation. There is no universally effective drug treatment but anticonvulsants may play a limited role in aborting the hallucinations. Physician awareness and empathy are the cornerstones of management.