Charles Bonnet syndrome: visual hallucination and multiple sclerosis

"My sister wants to kill me": A case report and systematic review of literature of co-occurring multiple sclerosis and psychosis

Background

Multiple sclerosis (MS) is a neurological disorder with demyelination of neuronal matter, especially of white matter, with multiple episodes occurring temporally. It has been associated with multiple neurological and psychiatric sequelae. Depression and other affective symptoms are commonly associated with MS. Previous research has also suggested that psychotic symptoms may co-occur with MS as well.

Material and Methods

A case report was prepared on the patient admitted to the inpatient unit. Subsequently, a systematic literature review of literature was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) model on three databases. Search terms included (MS OR multiple sclerosis) AND (Psychosis OR schizophrenia OR schizoaffective disorder OR psychotic OR hallucination OR delusion).

Results

The literature review led to an initial discovery of 2711 hits on PubMed, 1276 hits on PsycINFO, and 5429 hits on Embase. Some patients were diagnosed with MS at an earlier age with a later onset of psychosis, while some were initially diagnosed with psychosis (or schizophrenia) first and subsequently with MS. Psychotic symptoms observed included persecutory delusions, lack of insight, delusions of reference, auditory hallucinations, grandiose delusions, and passivity. The commonly prescribed antipsychotics included risperidone, olanzapine, quetiapine, and aripiprazole. The presence of co-occurring psychosis in MS patients underscores the need for a comprehensive evaluation of symptoms.

Conclusion

This case highlights the importance of conducting a magnetic resonance imaging (MRI) brain not only for initial onset psychosis but also for any sudden changes in patients who have had a relatively stable course. Moreover, psychosis can affect treatment adherence in MS, making it all the more critical to identify and manage it promptly.

Charles Bonnet syndrome in an elderly blind man with recurrent pituitary macroadenoma and optic nerve atrophy: A case report

Key Clinical Message

Charles Bonnet syndrome presents with complex visual hallucinations in a visually impaired or blind person. The case highlights complex neuropsychiatric manifestations due to pituitary macroadenoma in geriatrics requiring multi-collaborative care.

Abstract

An 81-year-old man presented with a 3-year history of vivid visual hallucinations preceded by visual impairment and recurrence of a pituitary macroadenoma. Remission of hallucination occurred within 2 weeks of 1.5 mg of haloperidol per oral once daily; this is a rare case of Charles Bonnet syndrome after recurrent pituitary macroadenoma.

The toxic metal hypothesis for neurological disorders

Multiple sclerosis and the major sporadic neurogenerative disorders, amyotrophic lateral sclerosis, Parkinson disease, and Alzheimer disease are considered to have both genetic and environmental components. Advances have been made in finding genetic predispositions to these disorders, but it has been difficult to pin down environmental agents that trigger them. Environmental toxic metals have been implicated in neurological disorders, since human exposure to toxic metals is common from anthropogenic and natural sources, and toxic metals have damaging properties that are suspected to underlie many of these disorders. Questions remain, however, as to how toxic metals enter the nervous system, if one or combinations of metals are sufficient to precipitate disease, and how toxic metal exposure results in different patterns of neuronal and white matter loss. The hypothesis presented here is that damage to selective locus ceruleus neurons from toxic metals causes dysfunction of the blood-brain barrier. This allows circulating toxicants to enter astrocytes, from where they are transferred to, and damage, oligodendrocytes, and neurons. The type of neurological disorder that arises depends on (i) which locus ceruleus neurons are damaged, (ii) genetic variants that give rise to susceptibility to toxic metal uptake, cytotoxicity, or clearance, (iii) the age, frequency, and duration of toxicant exposure, and (iv) the uptake of various mixtures of toxic metals. Evidence supporting this hypothesis is presented, concentrating on studies that have examined the distribution of toxic metals in the human nervous system. Clinicopathological features shared between neurological disorders are listed that can be linked to toxic metals. Details are provided on how the hypothesis applies to multiple sclerosis and the major neurodegenerative disorders. Further avenues to explore the toxic metal hypothesis for neurological disorders are suggested. In conclusion, environmental toxic metals may play a part in several common neurological disorders. While further evidence to support this hypothesis is needed, to protect the nervous system it would be prudent to take steps to reduce environmental toxic metal pollution from industrial, mining, and manufacturing sources, and from the burning of fossil fuels.

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.

Elemental imaging shows mercury in cells of the human lateral and medial geniculate nuclei

OBJECTIVE

Interference with the transmission of sensory signals along visual and auditory pathways has been implicated in the pathogenesis of hallucinations. The relay centres for vision (the lateral geniculate nucleus) and hearing (the medial geniculate nucleus) appear to be susceptible to the uptake of circulating mercury. We therefore investigated the distribution of mercury in cells of both these geniculate nuclei.

MATERIALS AND METHODS

Paraffin-embedded tissue sections containing the lateral geniculate nucleus were obtained from 50 adults (age range 20-104 years) who at autopsy had a variety of clinicopathological conditions, including neurological and psychiatric disorders. The medial geniculate nucleus was present in seven sections. Sections were stained for mercury using autometallography. Laser ablation-inductively coupled plasma-mass spectrometry was used to confirm the presence of mercury.

RESULTS

Ten people had mercury in cells of the lateral geniculate nucleus, and in the medial geniculate nucleus of three of these. Medical diagnoses in these individuals were: none (3), Parkinson disease (3), and one each of depression, bipolar disorder, multiple sclerosis, and mercury self-injection. Mercury was distributed in different groups of geniculate capillary endothelial cells, neurons, oligodendrocytes, and astrocytes. Mass spectrometry confirmed the presence of mercury.

CONCLUSION

Mercury is present in different combinations of cell types in the lateral and medial geniculate nuclei in a proportion of people from varied backgrounds. This raises the possibility that mercury-induced impairment of the function of the geniculate nuclei could play a part in the genesis of visual and auditory hallucinations. Although these findings do not provide a direct link between mercury in geniculate cells and hallucinations, they suggest that further investigations into the possibility of toxicant-induced hallucinations are warranted.

Hallucinations Experienced by Visually Impaired: Charles Bonnet Syndrome

Supplemental digital content is available in the text.

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.

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: Case series

Since its first description in 1760, Charles Bonnet syndrome (CBS) has been reported in many studies. The main characteristics are visual hallucinations, preserved awareness of unreal visions, and absence of psychotic symptoms. CBS can occur with lesions located anywhere along the central visual pathway, from the eye to the calcarine fissure.

Objective

To describe patients with CBS and carry out a review of the literature.

Methods

Six patients with visual hallucinations were evaluated in an outpatient memory clinic between 2001 and 2008, and their clinical characteristics recorded.

Results

Four patients were female, and the mean age was 74.5±16.9 years. Three patients had visual loss secondary to eye disease and three due to cerebral lesions. The visions consisted of animals, persons, moving objects, bizarre creatures or colored forms, and were considered disturbing by five patients. Five patients received treatment, and only three reported partial benefit from the therapy. Complete recovery was not seen in any of the subjects.

Conclusions

CBS is relatively rare and its recognition is important to avoid misdiagnoses with psychiatric or dementing illnesses.

Hallucinations in visually impaired individuals: an analysis of the National Comorbidity Survey Replication

OBJECTIVE

Charles Bonnet syndrome (CBS) is by complex visual hallucinations and ocular pathology causing vision loss. It has been considered that CBS occurs frequently in elderly visually handicapped patients and the hallucinations are limited to the visual modality. Three hypotheses we examined were: (1) whether visual impairments are associated with visual hallucinations (2) whether visual impairments are associated with auditory hallucinations (3) whether the development of visual and auditory hallucinations in patients with visual impairments is associated with age.

METHOD

Data from the National Comorbidity Survey Replication (NCS-R) in the United States were used to examine whether associations between visual impairments and visual hallucinations can be found in the general population, and whether such influences of visual impairments are limited to the visual modality and to specific age groups.

RESULTS

Prevalence of visual and auditory hallucinations in respondents with visual impairments were 12.8% (95% Confidence Interval (CI)=3.4-22.2%) and 7.1% (95%CI=2.6-11.6%) respectively. Although the point estimates were substantive, the odds ratios between visual impairments and existence of visual hallucinations or auditory hallucinations were not statistically significant (odds ratio (OR)=2.43, 95%CI=0.92-6.44, P=0.07 and OR=2.16, 95%CI=0.87-5.33, P=0.10, respectively) in the whole sample. Association between visual impairments and visual hallucination was significant (OR=3.09, 95%CI=1.06-8.99, P<0.05) only in the elderly (age group 60-), while significant association was found between visual impairments and auditory hallucinations in a younger age group (age group 18-39, OR=13.25, 95%CI=2.99-58.75, P<0.001).

CONCLUSION

Visual impairments act as a trigger for both visual and auditory hallucinations. In patients with visual impairments, the presence of visual hallucinations was associated with an age over 60, while the existence of auditory hallucinations was associated with an age under 39.

The Charles Bonnet syndrome: a review of recent research

PURPOSE OF REVIEW

The Charles Bonnet syndrome is a disorder of visual hallucinations typically occurring in older persons with vision impairment or deafferentation of the visual cortex. This review cites recent studies on Charles Bonnet syndrome and discusses treatment options. The numbers of affected persons will increase with aging of the population, making recognition and treatment important components of ophthalmologic care.

RECENT FINDINGS

The etiology of the Charles Bonnet syndrome is varied; most often it involves direct damage to the visual system (e.g. age-related macular degeneration, glaucoma) but it may also result from cerebral pathology interrupting connections between the eye and the occipital cortex. Case reports of different management approaches demonstrate the range of treatment options.

SUMMARY

This review suggests that the Charles Bonnet syndrome will affect an increasingly large number of older persons as the population ages and the occurrence of vision and cerebral disorders increases. Clinical trials of antipsychotic and other medications, as well as low-vision rehabilitation, are necessary to establish valid treatments for this disorder.

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.