Charles Bonnet Syndrome Hallucinations Research Articles

Charles Bonnet Syndrome With Superimposed Delirium

Charles Bonnet Syndrome (CBS) is diagnosed when a patient who is psychiatrically intact experiences visual hallucinations in the setting of significant visual acuity or field loss. The exact pathophysiology of the CBS hallucinations remains largely unknown. The main theories include the deafferentation theory and perceptual release theory. There are suspected neurotransmitters involved, including acetylcholine and dopamine. There is no defined treatment protocol with medication for CBS, but various psychotropic medications have been used with varying degrees of remission of symptoms.This case report describes a 64-year-old male with Charles Bonnet Syndrome in the setting of superimposed delirium. We note the different medications that were trialed to reduce his CBS symptoms and decrease episodes of behavioral disturbances. Clinical features of this rare syndrome with superimposed delirium are summarized in hopes of providing directions for management and future study.

Transcranial Direct Current Stimulation in the Treatment of Visual Hallucinations in Charles Bonnet Syndrome: A Randomized Placebo-Controlled Crossover Trial

To investigate the potential therapeutic benefits and tolerability of inhibitory transcranial direct current stimulation (tDCS) on the remediation of visual hallucinations in Charles Bonnet syndrome (CBS). Randomized, double-masked, placebo-controlled crossover trial. Sixteen individuals diagnosed with CBS secondary to visual impairment caused by eye disease experiencing recurrent visual hallucinations. All participants received 4 consecutive days of active and placebo cathodal stimulation (current density: 0.29 mA/cm2) to the visual cortex (Oz) over 2 defined treatment weeks, separated by a 4-week washout period. Ratings of visual hallucination frequency and duration following active and placebo stimulation, accounting for treatment order, using a 2× 2 repeated-measures model. Secondary outcomes included impact ratings of visual hallucinations and electrophysiological measures. When compared with placebo treatment, active inhibitory stimulation of visual cortex resulted in a significant reduction in the frequency of visual hallucinations measured by the North East Visual Hallucinations Interview, with a moderate-to-large effect size. Impact measures of visual hallucinations improved in both placebo and active conditions, suggesting support and education for CBS may have therapeutic benefits. Participants who demonstrated greater occipital excitability on electroencephalography assessment at the start of treatment were more likely to report a positive treatment response. Stimulation was found to be tolerable in all participants, with no significant adverse effects reported, including no deterioration in preexisting visual impairment. Findings indicate that inhibitory tDCS of visual cortex may reduce the frequency of visual hallucinations in people with CBS, particularly individuals who demonstrate greater occipital excitability prior to stimulation. tDCS may offer a feasible intervention option for CBS with no significant side effects, warranting larger-scale clinical trials to further characterize its efficacy.

That song in my head: a review on Musical Hallucinations

IntroductionHearing music inside our heads is frequent, however some hear it more vividly, constantly and involuntarily. Musical Hallucinations (MH), first described by Baillarger in 1846, are a complex type of auditory hallucination characterized by perception of melodies, music, or songs.ObjectivesThis work aims to review the literature considering MH.MethodsPubmed and Google Scholar search using MeSH term “musical hallucinations”ResultsMH occurs in 0.16% of the population. They´re usually perceived as frightening or annoying. Proposed mechanisms include spontaneous activity triggered by sensory deprivation from hearing impairment, like in visual hallucinations in Charles Bonnet syndrome, and some authors even include MH as a subtype of this syndrome. Indeed, 60% of all patients with MH have hearing impairment or deafness. Other less frequent causes include focal brain lesions involving the auditory pathway and cortex, temporal epilepsy, metabolic or drug intoxication. Psychiatric conditions are uncommon but not impossible, especially in affective disorders. MH most frequently consist in familiar tunes, sometimes of personal significance, religious songs (especially in older patients), childhood songs, folk and popular songs from the radio - suggesting that musical perception is never unlearned but represents a “parasitic memory”, an unchangeable memory feature which can be experienced by relevant neuronal circuit stimulation. Most patients with MH were reported to have no extraordinary musical skills.ConclusionsMH are rare and strongly associated with hearing loss, though investigation of other causes should be sought. Treating the underlying cause is important but remission is not guaranteed.DisclosureNo significant relationships.

0816 Chronic insomnia secondary to severe nocturnal visual hallucinations in Charles Bonnet syndrome; a challenging case to manage

Abstract Introduction Over 1 million Americans are blind. Charles Bonnet syndrome (CBS), a parallel to phantom limb syndrome and also known as release hallucinations, describes visual hallucinations in patients with severe visual loss and blindness. The prevalence of release hallucinations, though likely underreported, is believed to be 12 to 20% of visually impaired persons. Report of Cases: A 45-year-old male with past medical history of migraines presented to the hospital with what was determined to be a ruptured pituitary macroadenoma and as a result, lost complete visual function including pupillary reflexes. The patient subsequently experienced both simple and complex release hallucinations and was eventually diagnosed with Charles Bonnet syndrome. Most disturbing to the patient was the simple release hallucinations which was described as a bright white light in a honeycomb lattice predominately in his right visual field which lasted for hours. This phantom light was not consistently associated with any other symptoms and could occur at any time throughout the 24-hour day. Nocturnal symptoms occurred approximately 50% of nights and caused severe onset/maintenance insomnia and insufficient sleep duration. The patient tried therapy in addition to proper sleep hygiene without relief. He was trialed on several medications and the only one able to alleviate all but the worst of the phantom light was diazepam. The GABA-A receptor agonist finally allowed the patient an opportunity to sleep. His insomnia was then treated with once nightly temazepam, in addition to as needed diazepam. Approximately nine years after losing his vision, he was transitioned from temazepam to the tricyclic antidepressant amitriptyline, which offered improved relief from the phantom lights causing his insomnia. The patient continues to utilize once nightly amitriptyline with diazepam for breakthrough symptoms, though he still suffers significant impairment due to the phantom lights of his Charles Bonnet syndrome. Conclusion Treatment of Charles Bonnet syndrome is multifactorial and includes maintaining optimal eye care, stimulating senses, psychosocial therapy, and pharmacotherapy. Insomnia from release hallucinations remains difficult to manage, though GABA-A receptor agonists have shown some relief. Case reports of atypical antipsychotics and antidepressants, including melperone and agomelatine respectively, have demonstrated ability to improve release hallucinations. Support (If Any) Charles Bonnet Syndrome FAQs. Charles Bonnet Syndrome Foundation (Australia). https://www.charlesbonnetsyndrome.org/index.php/cbs/faq. Accessed December 15, 2021.Hsu HC, Huang YS, Fan WX, Chen TC. Charles Bonnet Syndrome (CBS): Successful Treatment of Visual Hallucinations Due to Vision Loss with Agomelatine in Three Cases. European Psychiatry. 2017;41(S1):S172-S172. doi:10.1016/j.eurpsy.2017.01.2065Pelak VS. Visual release hallucinations (Charles Bonnet syndrome). UpToDate. Waltham, MA: UpToDate; June 7, 2016; https://www.uptodate.com/contents/visual-release-hallucinations-charles-bonnet-syndrome.

Auditory Hallucinations in Charles Bonnet Syndrome: A Case Report

Auditory Hallucinations in Charles Bonnet Syndrome: A Case Report

Exacerbation of visual hallucinations in Charles Bonnet syndrome due to the social implications of COVID-19

ObjectiveCharles Bonnet syndrome (CBS) occurs secondary to sight loss, characterised by spontaneous visual hallucinations. Symptom manifestation can be influenced by social isolation. This research aims to evaluate the effect of...

Stimulus-Driven Cortical Hyperexcitability in Individuals with Charles Bonnet Hallucinations

Throughout the lifespan, the cerebral cortex adapts its structure and function in response to changing sensory input [1, 2]. Whilst such changes are typically adaptive, they can be maladaptive when they follow damage to the peripheral nervous system, including phantom limb pain and tinnitus [3, 4]. An intriguing example occurs in individuals with acquired ocular pathologies-most commonly age-related macular degeneration (MD) [5]-who lose their foveal vision but retain intact acuity in the peripheral visual field. Up to 40% of ocular pathology patients develop long-term hallucinations involving flashes of light, shapes, or geometric patterns and/or complex hallucinations, including faces, animals, or entire scenes, a condition known as Charles Bonnet Syndrome (CBS) [6, 7, 8]. Though CBS was first described over 250 years ago [9, 10], the neural basis for the hallucinations remains unclear, with no satisfactory explanation as to why some individuals develop hallucinations, while many do not. An influential but untested hypothesis for the visual hallucinations in CBS is that retinal deafferentation causes hyperexcitability in early visual cortex. To assess this, we investigated electrophysiological responses to peripheral visual field stimulation in MD patients with and without hallucinations and in matched controls without ocular pathology. Participants performed a concurrent attention task within intact portions of their peripheral visual field, while ignoring flickering checkerboards that drove periodic electrophysiological responses. CBS individuals showed strikingly elevated visual cortical responses to peripheral field stimulation compared with patients without hallucinations and controls, providing direct support for the hypothesis of visual cortical hyperexcitability in CBS.

Charles Bonnet Syndrome: Comorbidity may help in choosing the drug for therapy

Sir, I read with interest the article on Charles Bonnet Syndrome (CBS) by Cinar et al.[1] However, I wish to make the following observations: In the article, visual deterioration has been mentioned as one of the components of the triad to define CBS. The authors have rightly taken pains to confirm the other components of the triad, such as the normalcy of cognition by conducting neurological examination, electroencephalography, magnetic resonance imaging and mini-mental state examination, but, surprisingly, there is no mention of the best corrected visual acuity or a proper ophthalmological examination. As the patient was an 80-year-old and the medical history was significant for diabetes and hypertension, there could have been other associated ocular conditions such as age-related macular degeneration or diabetic retinopathy. Although glaucomatous vision loss can cause CBS, macular degeneration is supposed to be the most common condition associated with this syndrome,[2] and could have been the primary cause, along with glaucoma as the secondary cause. Improvement in blood sugar can also lead to a decrease in visual hallucinations in CBS[3] but, in this study, the glycemic status of the patient or the details of the medication history have not been given. The authors have written that their patient was started on a daily dose of 75 mg of pregabalin for diabetic neuropathy. It is unclear from the sentence whether the patient was primarily treated for diabetic neuropathy or CBS. If CBS was managed in the process of treating the diabetic neuropathy, then the 75 mg dose seems less than the dose usually recommended for neuropathy, to begin with.[4] Otherwise, the reasons for choosing pregabalin for treating CBS, such as the previous success of gabapentin in CBS and it being a safer congener with established efficacy in neuropathy also, should have been elaborated a little more.

The prevalence and clinical characteristics of Charles Bonnet syndrome in Chinese patients

ObjectiveThe aim of this study was to investigate the prevalence and characteristics of Charles Bonnet syndrome (CBS) in a group of Chinese older patients and to study whether CBS is associated with rapid eye movement behavior disorder (RBD). MethodsFour hundred and thirty-two consecutive patients aged 60 years and above were asked a standardized question to determine if they had symptoms of CBS. If they responded positively, a detailed questionnaire was orally administered to inquire into the details of the symptoms. ResultsThere were 238 men (55.1%) and 194 women (44.9%). Six (1.4%) patients of 432 had hallucinations attributable to CBS. The clinical characteristics of CBS hallucinations are quite variable between patients. No patient was pathologically confirmed to have RBD. ConclusionThis is the first report on the epidemiology of CBS in mainland China. CBS is not uncommon in elderly, visually handicapped Chinese patients. The natures of the hallucinations experienced were similar to those previously reported. None of the CBS patients had evidence of RBD. Further studies are needed to investigate the prevalence of CBS in the general population.

Charles Bonnet syndrome and Terson’s syndrome from subarachnoid hemorrhage: good news from bad news

Dear Editor, We read with interest the report by Cebulla et al. [1] reporting visual hallucinations associated with Charles Bonnet syndrome (CBS) in a patient with bilateral dense vitreous hemorrhage from subarachnoid hemorrhage. The authors report rapid improvement in her cognition and cessation of the hallucinations after pars plana vitrectomy was performed in one eye. This is consistent with earlier reports where improvement of visual acuity leads to a reduction or cessation of the hallucinations in CBS [2–4]. The authors referred to the “commonly limited prognosis for hallucinations” in CBS[1]. While it is true that the hallucinations do persist in some patients, in others these hallucinations may cease spontaneously after a period of time, even if the visual loss is irreversible. In fact, it has been suggested that an acute change in visual acuity may be the trigger for the onset of visual hallucinations in CBS [5, 6] and the hallucinations cease once the visual acuity has stabilized. Patients with CBS have been treated with a variety of drugs to control the hallucinations. However, in our experience, reassurance that the hallucinations are normal, and that they are not “mad” or suffering from a psychiatric disease, are a source of great relief to patients [3]. We would also like to point out that although older age is a risk factor for CBS, this condition can occur in patients of any age group [3], even in the pediatric age group [7, 8]. Therefore, it is important to consider this diagnosis even in younger patients who present with visual hallucinations without other neurological causes.

Visual Hallucinations in Charles Bonnet Syndrome Can Be Seen in Fluorodeoxyglucose-PET

Visual Hallucinations in Charles Bonnet Syndrome Can Be Seen in Fluorodeoxyglucose-PET

Visual Hallucinations in Charles Bonnet Syndrome Can Be Seen in Fluorodeoxyglucose-PET

Visual Hallucinations in Charles Bonnet Syndrome Can Be Seen in Fluorodeoxyglucose-PET

P0010 EARLY ORTHOGERIATRIC INTERVENTION IN NECK OF FEMUR FRACTURES DECREASES LENGTH OF HOSPITAL STAY

Introduction: -Visual hallucinations are generally unpleasant and distressing especially when they are part of a complex psychiatric condition. However, when it occurs as a sole manifestation in the presence of normal insight, it is often non distressing. Visual hallucination in the presence of normal insight and cognition is Charles Bonnet Syndrome (CBS). Although it commonly occurs in patients with visual impairment it is not a prerequisite for diagnosis. Objectives: To illustrate different types of visual hallucinations in CBS, its management and explore the literature. Materials & methods: We report 3 cases of Charles Bonnet Syndrome and discuss the details of associated visual hallucination Results: Case one 93 year old lady presented with one week history of seeing images of her friends and relatives and sometimes pleasant images like angels. These images were stereotyped, recurrent, occurring mostly when she was alone in the evenings. She had full insight of her hallucinations and therefore she was not frightened of them. She had marked visual impairment. The clinical examination and investigations did not reveal any other cause. A diagnosis of CBS was made and she was managed successfully. Case two A 92 year old women presented with the history of recurrent episodes of seeing the images of her son-in-law walking around her house. She had complete insight and started to ignore them from the onset. Clinical examination revealed no evidence of cognitive impairment. Importantly, she had no visual impairment. CT head scan showed changes consistent with small vessel disease only. Her management was based on reassurance that this was not a psychiatric condition and she became free of hallucinations within a month. Case three A 75 year women had an episode of seeing a ‘jagged edge box’ with ‘wavy lines’. She experienced this in both eyes simultaneously but was not perturbed. Her cognitive status and neurological examination were normal. Although she appeared stressed, she did not display evidence of depression. Neuro imaging and blood tests were also normal. She was reassured about the nature of her visual hallucination and her symptom did not recur during the follow up over the next one year. Discussion & conclusion: A careful history and consideration of CBS as a possible cause of visual hallucination can lead to reduction of unnecessary investigations and associated anxiety. Unlike those associated with psychiatric symptoms, visual hallucination in CBS responds adequately to reassurance alone.

P0009 VISUAL HALLUCINATIONS- A RATHER PLEASANT EXPERIENCE! CHARLES BONNET SYNDROME

Introduction: -Visual hallucinations are generally unpleasant and distressing especially when they are part of a complex psychiatric condition. However, when it occurs as a sole manifestation in the presence of normal insight, it is often non distressing. Visual hallucination in the presence of normal insight and cognition is Charles Bonnet Syndrome (CBS). Although it commonly occurs in patients with visual impairment it is not a prerequisite for diagnosis. Objectives: To illustrate different types of visual hallucinations in CBS, its management and explore the literature. Materials & methods: We report 3 cases of Charles Bonnet Syndrome and discuss the details of associated visual hallucination Results: Case one 93 year old lady presented with one week history of seeing images of her friends and relatives and sometimes pleasant images like angels. These images were stereotyped, recurrent, occurring mostly when she was alone in the evenings. She had full insight of her hallucinations and therefore she was not frightened of them. She had marked visual impairment. The clinical examination and investigations did not reveal any other cause. A diagnosis of CBS was made and she was managed successfully. Case two A 92 year old women presented with the history of recurrent episodes of seeing the images of her son-in-law walking around her house. She had complete insight and started to ignore them from the onset. Clinical examination revealed no evidence of cognitive impairment. Importantly, she had no visual impairment. CT head scan showed changes consistent with small vessel disease only. Her management was based on reassurance that this was not a psychiatric condition and she became free of hallucinations within a month. Case three A 75 year women had an episode of seeing a ‘jagged edge box’ with ‘wavy lines’. She experienced this in both eyes simultaneously but was not perturbed. Her cognitive status and neurological examination were normal. Although she appeared stressed, she did not display evidence of depression. Neuro imaging and blood tests were also normal. She was reassured about the nature of her visual hallucination and her symptom did not recur during the follow up over the next one year. Discussion & conclusion: A careful history and consideration of CBS as a possible cause of visual hallucination can lead to reduction of unnecessary investigations and associated anxiety. Unlike those associated with psychiatric symptoms, visual hallucination in CBS responds adequately to reassurance alone.

Complex visual hallucinations in Charles Bonnet Syndrome are associated with a hypermetabolism in the visual associative cortex

Complex visual hallucinations in Charles Bonnet Syndrome are associated with a hypermetabolism in the visual associative cortex

Charles Bonnet Syndrome: Two Case Reports

Charles Bonnet Syndrome: Two Case Reports

Charles bonnet syndrome associated with age-related macular degeneration.

The visual hallucinations in Charles Bonnet syndrome (CBS) are most commonly attributed to release phenomena that arise due to a paucity of sensory input to visual association areas of the cerebral cortex (Cogan's sensory deprivation theory of visual hallucinations). The authors wished to gain further insight into this mechanism behind CBS by examining a patient who experienced reversible visual hallucinations. The authors present a 77-year-old man with a history of severe age-related macular degeneration who experienced formed and moving visual hallucinations associated with CBS shortly after a retinal pigment epithelial detachment (RPED) in his right eye. His visual acuity had been reduced to 20/400 in the right eye. Visual acuity improved to 20/50 in the right eye after a series of Macugen injections led to RPED resolution as evidenced by optical coherence tomography and fluorescein angiography. The visual hallucinations abruptly ceased after this dramatic improvement in visual acuity. Reestablishment of high resolution visual input leads to a dramatic and almost immediate increase in the stimulus threshold of visual cortex cells as reflected by resolution of symptoms. The subthreshold signals that reach consciousness to produce visual hallucinations in CBS are thus immediately mitigated.

Vision Rehabilitation and Charles Bonnet Syndrome

Purpose: To evaluate the prevalence of visual hallucinations in Charles Bonnet Syndrome (CBS) among patients at a Low Vision Clinic. To determine whether Low Vision Rehabilitation (LVR) intervention results in a decrease of these visual hallucinations. Methods: We surveyed 50 consecutive new patients in a low vision clinic to determine whether they had experienced visual hallucinations consistent with CBS. All patients were: questioned about the presence of visual hallucinations; given an educational handout that described CBS and reassured them of the benign nature of these hallucinations; and administered Folstein's Mini Mental Status Examination (MMSE). During their low vision examination, all patients received low vision aids to improve their visual function. At follow-up patients who had symptoms of CBS were administered a second survey to evaluate whether they had experienced any change in the frequency of their visual hallucinations. Results: Of the 50 patients surveyed, 12 of 50 (24%) had visual hallucinations typical of CBS. 6 of these 12 patients (50%) had daily recurring hallucinations. At mean follow-up of 34.9 +/−30 days, a second survey was administered to 11 of the 12 patients diagnosed with CBS. One patient was lost to follow-up. Three of the 11 patients (27.3%) experienced a decrease in the frequency of their hallucinations by 43.33% +/−30.55%. Eight of 11 patients (72.7%) did not note a change in their symptoms. Conclusions: It is important to include direct questions regarding visual hallucinations in the case history of a low vision examination. LVR may decrease the frequency of CBS hallucinations in some patients. Rehabilitation strategies should include low vision devices that allow for improved visual function and patient education to provide needed reassurance.